© 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

© 2009 Cengage Learning. All Rights Reserved. Regulation of Hospitals

© 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.

© 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.

© 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.

© 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.

© 2009 Cengage Learning. All Rights Reserved. Regulation of Insurance

© 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

© 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

© 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

© 2009 Cengage Learning. All Rights Reserved. Federal Regulations

© 2009 Cengage Learning. All Rights Reserved. Employment Retirement Income Security Act 29 U.S.C  Established standards for pension and welfare plans

© 2009 Cengage Learning. All Rights Reserved. Consolidated Omnibus Budget Reconciliation Act 29 U.S.C  COBRA amended ERISA and other statutes  Provides for extended health insurance coverage

© 2009 Cengage Learning. All Rights Reserved. Health Insurance Portability and Accountability Act  Extended scope of ERISA  Changed limitations of pre-existing conditions