© 2009 cengage learning. all rights reserved. state and federal roles in health care regulation

15
© 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

Upload: christine-andrews

Post on 23-Dec-2015

212 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

State and Federal Roles in Health Care

Regulation

Page 2: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Agenda

State and federal regulations for: hospitals insurance

Page 3: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Regulation of Hospitals

Page 4: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Patient Safety

Patient Safety and Quality Improvement

Act mandates that: Patient Safety Organizations collect,

aggregate, and analyze patient safety event information.

Page 5: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

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.

Page 6: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Conditions of Participation

Any hospital that participates in Medicare must follow CoPs set by federal regulations of CMS.

CoPs address minimum health and safety.

Page 7: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

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.

Page 8: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Regulation of Insurance

Page 9: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

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

Page 10: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

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

Page 11: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

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

Page 12: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Federal Regulations

Page 13: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Employment Retirement Income Security Act

29 U.S.C. 1001-1461

Established standards for pension and welfare plans

Page 14: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Consolidated Omnibus Budget Reconciliation Act

29 U.S.C. 1161

COBRA amended ERISA and other statutes Provides for extended health insurance

coverage

Page 15: © 2009 Cengage Learning. All Rights Reserved. State and Federal Roles in Health Care Regulation

© 2009 Cengage Learning. All Rights Reserved.

Health Insurance Portability and Accountability Act

Extended scope of ERISA Changed limitations of pre-existing

conditions