Healthcare And American Law: Who's In Charge?

Health law is a multidisciplinary field that focuses on the regulations and policies governing the healthcare industry and healthcare itself in both the government and private sectors. It affects legal issues related to medical providers, health insurers, patients, and government agencies. The American Health Care Act of 2017, also known as the Patient Protection and Affordable Care Act (ACA), is a comprehensive health care reform law enacted in March 2010 with three primary goals: making affordable health insurance available to more people, expanding the Medicaid program, and supporting innovative medical care delivery methods. The ACA offers rights and protections to consumers, such as ending pre-existing condition discrimination, providing free preventive services, and improving access to care. Healthcare lawyers play a crucial role in the industry by providing legal advice and representation to healthcare providers, hospitals, insurance companies, and government agencies. They help navigate complex regulations, provide guidance on compliance, and advocate for patients' rights.

The Affordable Care Act (ACA)

The ACA has introduced a range of rights and protections for people in the US. For example, insurance plans are now required to cover people with pre-existing health conditions, including pregnancy, without charging more. The ACA also provides free preventive care, gives young adults more coverage options, and ends lifetime and yearly dollar limits on essential health benefits. It holds insurance companies accountable for rate increases and makes it illegal for them to cancel a person's health insurance because they get sick.

The ACA also has implications for employers, as it includes requirements regarding health care coverage. The specific requirements depend on the size and structure of the workforce. Self-employed people without employees are not subject to these requirements.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) is a US law that sets the standard for sensitive patient data protection. It consists of five titles, each covering different aspects of health insurance and patient privacy.

HIPAA covers all persons working in healthcare, non-patient care employees, health plans, and electronic medical record companies. The primary goals are to limit the use of protected health information to those with a "need to know" and to penalize those who do not comply with confidentiality regulations. This includes any healthcare information with an identifier that links a patient to their healthcare information, such as their name, social security number, or address.

The HIPAA Privacy Rule and the HIPAA Security Rule are two key components of the legislation. The Privacy Rule establishes national standards for protecting certain health information, giving patients more control over their health data and setting boundaries on how companies can use and disclose it. The Security Rule complements this by outlining regulations for protecting electronic protected health information (ePHI), ensuring its confidentiality, integrity, and availability. It defines three areas of safeguards: administrative, physical, and technical, which are designed to protect ePHI from unauthorized access and use.

Medicare

In 2022, Medicare provided health insurance for approximately 65 million individuals, including over 57 million people aged 65 and older and about 8 million younger people. According to annual reports, Medicare covers about half of the healthcare expenses of those enrolled, with enrollees covering most of the remaining costs through additional private insurance, Medicare Part D prescription drug plans, or Medicare Part C (Medicare Advantage) plans.

The CMS, a component of the U.S. Department of Health and Human Services (HHS), administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and parts of the Affordable Care Act (ACA). The Social Security Administration determines Medicare eligibility and collects most premium payments for the program.

Medicaid

In all states, Medicaid provides coverage for certain low-income individuals and families, pregnant women, the elderly, and people with disabilities. Some states have expanded their Medicaid programs to cover all adults or people below a certain income level, regardless of other factors. This expansion of Medicaid, which was a key provision of the Affordable Care Act (ACA), has significantly increased access to health insurance for low-income populations.

The eligibility requirements for Medicaid vary depending on the state. Factors that are typically considered include income, household size, family status (such as pregnancy or having young children), disability status, age, and other factors. To apply for Medicaid, individuals must provide documentation such as proof of income, citizenship or immigration status, and other relevant information.

Anti-Kickback Statute

The Anti-Kickback Statute is a federal law that prohibits providers of services or goods covered by a federal healthcare program from knowingly and willingly soliciting, receiving, offering, or paying remuneration, directly or indirectly, overtly or covertly, in cash or in kind, to induce the referral of an individual or the furnishing of goods or services for which payment may be made under a federal healthcare program. The law is codified at 42 U.S.C. § 1320a-7(b) and has been in place since 1972.

The Anti-Kickback Statute is an intent-based statute, meaning that to prove a violation, there must be evidence that the person or entity "knowingly and willfully" violated the law. The statute covers federal health benefits programs such as Medicare, Medicaid, TriCare/Civilian Health and Medical Program of the Uniformed Services (Champus), and the Federal Employee Health Benefits Program (FEHBP).

Violations of the Anti-Kickback Statute can result in a range of penalties, including criminal penalties, civil sanctions, and exclusion from participation in federal healthcare programs. Criminal penalties can include fines of up to $100,000 per violation and imprisonment of up to ten years. Civil sanctions can include civil monetary penalties, exclusion from federal or state healthcare programs, and treble damages.

The Anti-Kickback Statute is an important tool in combating healthcare fraud and abuse and plays a crucial role in ensuring the quality and safety of medical care while protecting the rights and interests of all parties involved in the healthcare system.

To determine if a business arrangement violates the Anti-Kickback Statute, it is essential to consider various factors, including the nature of the business, the existence of referrals or potential referrals, the types of value exchanged, and the extent of federal or state funding involved in the healthcare services provided.

Frequently asked questions