Licensure & Regulatory Compliance

Male pointing to ComplianceHospitals are required to meet certain Conditions of Participation to participate in the Centers for Medicare & Medicaid Services’ program, and are subject to state hospital licensure rules. MHA staff provide resources and tools to assist hospitals in meeting these ever-changing requirements.

  • Federal Laws and Regulations
  • State Laws and Regulations
  • Compliance

Medicare Regulations

MHA has developed resources to assist hospitals in complying with state hospital licensure regulations and the Medicare Conditions of Participation. These tools are designed to improve staff knowledge of the regulations, proactively identify and correct regulatory issues to improve compliance, and to decreases the number and length of surveys on cited deficiencies.

In 2015, the U.S. Congress enacted new laws requiring hospitals to provide patients who received observation care with written notice of their status. The notice was to outline coverage implications for potential out-of-pocket expenses and encourage patients to contact their payer for specific information related to their individual plans. On Dec. 9, 2016, the Centers for Medicare & Medicaid Services released the final Medicare Outpatient Observation Notice and accompanying form instructions. Hospitals must begin using the MOON no later than Wednesday, March 8. MHA has developed educational materials to help explain observation care, specifically how it relates to Medicare billing and three-day stay requirements for skilled nursing care. MHA authorizes the revision of these materials to meet organizational and/or patient population needs.

MHA Issue Briefs

Published by MHA, these issue briefs discuss reports, congressional proposals and actions from federal agencies.

Federal Inside Tracks

MHA Self-Assessment Checklists

MHA has developed self-assessment checklists for acute care hospitalscritical access hospitals and rural health clinics that will aid them with their internal assessments of their compliance with state hospital licensure regulations, Medicare Conditions of Participation and the interpretative guidelines.

Missouri Hospital and Professional Licensure Rules

Changes in Local Coverage Determinations Regarding Sleep Studies

Political and Lobbying Legal Guidelines for Hospitals

Although hospitals and their employees may participate in the political and lobbying process, there are numerous caveats and restrictions. Organizations and employees must be aware of federal and state lobbying laws, as well as federal laws governing tax-exempt status. Institutions that are government entities, like public hospitals, also must be mindful of state laws prohibiting political activities by state entities.

Lobbying Disclosure Act


EMTALA, also known as the Emergency Medical Treatment & Labor Act, ensures that the public has access to emergency services, regardless of a person's ability to pay for medical services. The Centers for Medicare & Medicaid Services released revisions to Appendix V, Part II, EMTALA Interpretive Guides. The appendix contains information previously released through survey and certification memos issued from April 2005 through March 2009.

Webinar:  CMS Will Show No Mercy:  Ensuring EMTALA Compliance for Psychiatric Patients in the ED
Recording | PowerPoint Presentation


The Health Insurance Portability and Accountability Act, better known as HIPAA, protects individuals’ health information from inappropriate uses or disclosures. The law establishes standards for the release of protected health information by covered entities, which include health care providers, health plans and health care clearinghouses (such as medical billing services). Protected health information includes medical information in both printed and electronic form. In addition to the privacy rule, which governs the disclosure of protected health information, HIPAA security regulations require covered entities to maintain certain physical plant and electronic standards to guard against inappropriate access to PHI. For a summary of the HIPAA Privacy Rule, please visit the U.S. Department of Health & Human Services' website.

MHA Distributes Physician Bona Fide Employment Guide

This guide, developed with the assistance of Lathrop and Gage LLP, is intended to be a resource for hospitals exploring the option of employing physicians or reviewing their agreements with currently employed physicians. We hope members find this to be a valuable resource.