© 2009 cengage learning. all rights reserved. state and federal roles in health care regulation
TRANSCRIPT
© 2009 Cengage Learning. All Rights Reserved.
State and Federal Roles in Health Care
Regulation
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Agenda
State and federal regulations for: hospitals insurance
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Regulation of Hospitals
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Patient Safety
Patient Safety and Quality Improvement
Act mandates that: Patient Safety Organizations collect,
aggregate, and analyze patient safety event information.
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Certificates of Need
Some states have CON laws that limit: construction of new hospitals number of beds allowed sale or transfer of ownership, and closure of existing hospitals without state
approval.
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Conditions of Participation
Any hospital that participates in Medicare must follow CoPs set by federal regulations of CMS.
CoPs address minimum health and safety.
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Accreditation
Hospitals that participate in Medicare are mandated to be accredited though a physical site visit, an examination of the hospital’s policies and procedures, and an assessment of the number and qualifications of hospital personnel.
Accreditation may be done by an organization.
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Regulation of Insurance
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State Regulation
McCarran-Ferguson Act and the Business of Insurance Elements of insurance contract Criteria for business of insurance
Role of the NAIC State commissioners of insurance
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Types of Health Care Insurers
Indemnity contracts Coverage is usually for catastrophic
illnesses, not preventative care Preferred provider organizations
Beneficiaries choose from panel of providers at different payment levels
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Types of Health Care Insurers contd.
Health maintenance organizations (or managed care organizations) Many types exist
Point of service plans Similar to PPO
Third party administrator
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Federal Regulations
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Employment Retirement Income Security Act
29 U.S.C. 1001-1461
Established standards for pension and welfare plans
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Consolidated Omnibus Budget Reconciliation Act
29 U.S.C. 1161
COBRA amended ERISA and other statutes Provides for extended health insurance
coverage
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Health Insurance Portability and Accountability Act
Extended scope of ERISA Changed limitations of pre-existing
conditions