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State and Federal Roles in Health Care Regulation

State and Federal Roles in Health Care Regulation. Agenda. State and federal regulations for: hospitals insurance. Regulation of Hospitals. Patient Safety. Patient Safety and Quality Improvement Act mandates that:

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State and Federal Roles in Health Care Regulation

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

  2. Agenda • State and federal regulations for: • hospitals • insurance © 2009 Cengage Learning. All Rights Reserved.

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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

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

  9. 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.

  10. 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.

  11. 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.

  12. Federal Regulations © 2009 Cengage Learning. All Rights Reserved.

  13. Employment Retirement Income Security Act 29 U.S.C. 1001-1461 • Established standards for pension and welfare plans © 2009 Cengage Learning. All Rights Reserved.

  14. Consolidated Omnibus Budget Reconciliation Act29 U.S.C. 1161 • COBRA amended ERISA and other statutes • Provides for extended health insurance coverage © 2009 Cengage Learning. All Rights Reserved.

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

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