Private health insurance is regulated at both the state and federal levels, creating a complex legal landscape that healthcare providers, insurers, and employers must navigate. While the Affordable Care Act (ACA), Employee Retirement Income Security Act (ERISA), and federal anti-fraud laws establish national standards, each state has its own set of rules governing policy coverage, provider networks, premium rates, claims handling, and consumer protections. Noncompliance can lead to fines, penalties, litigation, and loss of licensure.
This course provides an in-depth legal analysis of state-specific private insurance regulations, focusing on policy requirements, consumer protection laws, provider reimbursement rules, network adequacy standards, and enforcement actions. Students will gain expertise in understanding state insurance laws, handling disputes, managing compliance programs, and responding to regulatory audits and enforcement actions.
Course Objectives
By the end of this course, students will:
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Understand the State and Federal Regulatory Framework for Private Insurance Plans – Analyze the role of state insurance commissioners, ERISA preemption, and ACA compliance.
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Evaluate State-Mandated Insurance Requirements for Coverage and Benefits – Learn how states regulate essential health benefits, prior authorization, and provider access.
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Examine Key Consumer Protection Laws Governing Private Health Insurance – Study state laws on unfair claims practices, balance billing, and surprise medical bills.
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Analyze Provider Reimbursement Regulations and Payment Dispute Resolution – Review state laws on prompt payment, arbitration for claim denials, and network adequacy enforcement.
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Assess Best Practices for Ensuring Compliance with State-Specific Insurance Laws – Develop internal compliance programs, risk mitigation strategies, and contract negotiation tactics.
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Explore Legal Challenges Related to Insurance Plan Network Restrictions and Provider Disputes – Investigate contractual disputes, out-of-network billing conflicts, and insurer-provider litigation.
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Identify Strategies for Responding to State Insurance Department Investigations and Complaints – Learn how to handle audits, subpoenas, and consumer complaints against insurers.
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Prepare for Future Trends and Legislative Changes in State Insurance Regulation – Examine proposed policy reforms, state vs. federal conflicts, and the evolving role of state insurance regulators.
