Regulation Flashcards
Regulation
Regulation refers to a rule or directive maintained by an authoritative body.
Both private organizations and public agencies in the United States regulate the healthcare delivery system.
Regulators enforce laws, ensure that tasks are completed, and that protections are in place so that the healthcare system functions and so that providers and patients are safe.
If these laws, tasks or protections are not enforced, then the regulatory body can sanction and/or fine healthcare providers, pharmaceutical or biomedical companies, scientists, diverse healthcare organizations, insurance companies, and third-party administrators for failing to comply.
U.S. Health Care Delivery System’s Four Functional Parts
Financing- gov’t and employer
Insurance- Medicaid, Medicare, PPOs, HMOs, 176+ insurance corporations and a Centers for Medicare and Medicaid (CMS)
Delivery- providers and suppliers
Payment- reimbursement and OOP
Financing
Social Security Act 1965, Titles 18, 19 and 21 discuss how Medicare, Medicaid and CHIP are financed
However, when it comes to private insurance, since it is interstate commerce, it is largely regulated by states.
McCarran-Ferguson Act 1945 reaffirms the power of states to regulate and tax insurance products of third-party payers (Government Accountability Office, 2005).
Many, if not all, states have provisions in their codes to prohibit insurers from engaging in unfair or deceptive acts or practices in their states (Government Accountability Office, 2005).
However, beginning in 2011 as part of the ACA, CMS took over the review of health insurance rates increasing in excess of 10% annually from some states due to a lack of or inadequate state regulation of health insurance products sold to individuals and small businesses (The New York Times, 2011).
Insurance
ACA 2010 states that the DHHS oversees insurance on healthcare.gov and state healthcare marketplaces where people can buy health insurance.
ACA 2010 lists consumer protections so that insurance companies do not limit the essential package of services covered, discriminate based on pre-existing conditions or gender, and increase or terminate someone’s health insurance because they become “too expensive.”
ERISA 1974 sets minimum standards to protect individuals participating in most voluntarily established pension and health insurance private sector employee benefit plans. ERISA governs the administration of these plans if employers self-insure and defines how disputes are handled.
ERISA does not regulate benefits to the extent that the states do.
The National Committee for Quality Assurance (NCQA) ensures the quality of managed care plans. It was established in 1991 to provide standard and objective information about HMOs.
Delivery through organizations
Hospitals
Regulated by the Joint Commission, CMS, ACA 2010, local and state public health agencies
Clinics
DHHS regulates any facility that receives CMS payments
Federally-Qualified Health Centers (FQHCs)
Community health centers
Private clinics are overseen by state agencies & CMS
Skilled Nursing Facilities
Licensed by the state to operate and do business
Certified by CMS to admit patients that are publicly insured
