Health Care & Hospitalization

Health care and hospitalization law are federal and state laws that encompass public health, mental health, private health insurance matters, contracts, administrative law, financing, torts, corporation, antitrust, and ethics. Health care law's wide foundation can be attributed to the wide range of issues it encompasses. From genetic testing and the rising cost of health insurance to bioterrorism and malpractice, health care law covers it all.

Federal health law focuses on the activity of the Department of Health and Human Services (HHS). It administers a wide variety of agencies and programs, like providing financial assistance to needy individuals; conducting medical and scientific research; providing health care and advocacy services; and enforcing laws and regulations related to human services. An important part of the HHS are the Centers for Medicare and Medicaid Services, which oversee the Medicare and Medicaid Programs, State Children's Health Insurance Program (SCHIP), Health Insurance Portability and Accountability Act of 1996 (HIPAA), and Clinical Laboratory Improvement Amendments (CLIA). Their goal is to ensure that elderly and needy individuals receive proper medical care.

Individual states also have laws pertaining to public health. Check with a qualified health law attorney in your area for more information. In addition to public health issues, both the federal government and state governments also regulate private health insurance.

What is private health insurance?

Private health insurance originated with the Blue Cross system in 1929. The underlying principle was to spread the risk of high hospitalization bills between all individuals. Typical private insurance plans include health maintenance organizations (HMO's), Preferred Provider Organizations (PPO's) and fee-for-service plans.

What is an HMO?

An HMO provides health services through a network of doctors, hospitals, laboratories, etc. The health care providers may either be HMO employees or have some other contract arrangement with the HMO. HMO plans typically pay providers a monthly set amount regardless of the amount of services performed. When you enroll in an HMO, you choose one of the doctors as your primary care provider (PCP) to manage your health care. Whenever you need health care, you first consult your primary care provider; he or she then may refer you to an HMO-approved specialist.

HMO's are governed by federal and state laws. The main federal law that governs HMO's is the Health Maintenance Organization Act of 1973, and each state has its own set of laws.

What is a Preferred Provider Organization (PPO)?

Preferred Provider Organizations (PPO) are not insurance carriers but groups of providers who sell their services by contract to carriers.

What are fee-for-service plans?

Fee-for-service plans allow subscribers to select their own providers and receive direct reimbursement of valid health-care costs. Although these plans are less common today, they may be offered by either HCSCs or commercial carriers.

What are point-of-service plans?

Point-of-service plans allow their subscribers to go to providers outside the network, but usually do not reimburse costs at the same level as network providers.