Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); clarification of the CHAMPUS exclusion of unproven drugs, devices and medical treatments and procedures--DoD. Final rule

This final rule clarifies the CHAMPUS exclusion of unproven drugs, devices and medical treatments and procedures and describes the process that the Office of CHAMPUS follows in determining when such drugs, devices, treatments and procedures have moved from the status of unproven to the position of proven medical effectiveness. This clarification is necessary to ensure the CHAMPUS beneficiary and provider population understand the process the Office of CHAMPUS (OCHAMPUS) follows prior to endorsement by CHAMPUS of a new emerging medical technology, drug, or device for which the safety and efficacy have been proven.

The logic of tax-based financing for health care

Employment-based health insurance faces serious problems. For the first time, the number of Americans covered by such health insurance is falling. Employers strongly oppose the employer mandate approach to extending health insurance. Employment-based financing is regressive and complex. Serious debate is needed on an alternative solution to financing health care for all Americans. Taxation represents a clear alternative to employment-based health care financing. The major criterion for choosing a tax is equity, with simplicity a second criterion. An earmarked, progressive individual income tax is a fair and potentially simple tax with which to finance health care. The political feasibility of such a tax is greater than that of employer mandate legislation.

Disability & ADA: Sixth Circuit affirms congressional intent of Title III

Disability & ADA: Sixth Circuit Affirms Congressional Intent of Title III

In an appeal from a claim brought under Title III of the Americans with Disabilities Act, the U.S. Court of Appeals for the Sixth Circuit held in Parker v. Metropolitan Life Insurance CO. that Title III's prohibitions do not apply to employer-sponsored benefit plans. The court reasoned that employer- sponsored plans do not qualify under Title III because it prohibits discriminatory practices by places of public accommodation and employer sponsored plans are not goods offered by places of public accommodation. The court also stated that the purpose of the ADA was to prevent discrimination among nondisabled and disabled persons, not to ensure equal treatment for people with different disabilities.

The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191)

The purpose of this article is to provide a general overview and reference source for the Health Insurance Portability and Accountability Act, which was signed into law by President Clinton last August. The focus of the article is on Title I--Improved Availability and Portability of Health Insurance Coverage, and on Title III--Tax-Related Health Provisions. The author points out that due to the trend towards an incremental approach to health care legislation, this act must be viewed as one of a series of initiatives being taken by the federal government intended to impact the cost of the U.S. health care delivery system.

What benefits managers should know about the Mental Health Parity Act of 1996

In consideration of the statutory requirements of the Mental Health Parity Act of 1996, the author stresses that benefits managers should consider three issues. First, the financial impact of the act should be minimal for most plans. Second, minimal compliance may require more extensive changes to the plan than originally anticipated. Finally, the process of compliance offers opportunity to examine broader issues of mental health coverage. The article explains what the act does and does not require. The article concludes with a presentation of a comparative analysis of the cost impact of the act on five prototype plan designs.

ERISA preemption. Colleton Regional Hospital v. MRS Medical Review Systems Inc

ERISA preempts state law claims brought by hospitals against medical utilization review firm including claims of tortious interference with contracts, defamation, unfair trade practices, bad faith refusal to pay claims and improper claims practices.

Collectively bargained public health benefit plans

The marketplace for health benefits for public sector employees is large and complex with a great variety of approaches for providing care and a difficult patchwork of regulatory and collective bargaining regulation to deal with in designing a plan. Public sector workers' plans are subject to an additional constraint provided by the political nature of the process. The products sold to public sector plans are not regulated as ERISA plans, given the exclusion of government plans and the differential regulation of collectively bargained plans under the HMO act. This article attempts to guide the reader through some of the difficulties of this marketplace, pointing out pitfalls and opportunities where they appear.

ERISA preemption. St. Francis Medical Center v. Blue Cross and Blue Shield of Kansas, Inc

ERISA preempts hospital's state law action challenging insurer's rule banning health plan participants from assigning their benefit claims to health care providers who had not signed contracts with insurer.

Health care fraud and abuse: new weapons, new penalties, and new fears for providers created by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA")

The Health Insurance Portability and Accountability Act of 1996 may well be the most significant increase ever in the federal government's health care fraud and abuse enforcement authority. This new authority coupled with increased scrutiny of the health care industry generally creates a compelling incentive for health care facilities to develop corporate compliance programs.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); five separate changes--DoD. Final rule

This final rule addresses five separate changes to comply with provisions affecting CHAMPUS. These changes will update this part to include as a benefit, a screen to check for the level of lead in the blood of an infant; to eliminate the implied statement that ambulance services are covered only to, from, and between hospitals; to include other forms of prescribed contraceptives by eliminating the reference that limits prescribed contraceptives only to those taken orally; to identify three additional Gulf Conflict groups eligible for the delay in the increased deductible; and to establish lower limits on the fiscal year catastrophic cap from $10,000 to $7,500 for all eligibles except dependents of active duty personnel, whose limit remains at $1,000.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY97 DRG updates--DoD. Notice of DRG revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1997 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).