HSM 546 Health Insurance Management Complete NEW Course
HSM 546 Health Insurance Management Complete NEW Course

HSM 546 Health Insurance Management Complete NEW Course

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HSM 546 Health Insurance Management Complete NEW Course

Description

HSM 546 Health Insurance Management Complete NEW Course

HSM 546 Health Insurance Management Complete NEW Course

HSM 546 Health Insurance and Management Complete NEW Course

You Decide Week 2 | Patient Protection and Affordability Act Week 3 | Group Course Project-Aetna| HSM 546 Aetna Course Project Individual Paper Week 7 | Discussions Week 1-7 | Final Exam

A+

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HSM 546 CEO Southside HMO You Decide Week 2

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Scenario/Summary

You are the chief executive officer of Southside HMO, which serves 495,000 members throughout the eastern region of the United States. It has come to your attention that several members or patients who participate in your plan have filed a complaint that your HMO plan does not provide quality healthcare delivery. Several patients have been denied healthcare services to see specialists to whom they were referred by their primary care providers.

Your Role/Assignment

The board of directors has asked that you provide a 750-word report detailing your strategies and recommendations to investigate the complaints and to identify strategies to ensure that quality management initiatives are in place to make sure that quality healthcare services are provided to all members. The strategies and recommendations should be as specific as possible and include the resources needed for implementation. Your primary text and journal and website research must be used as a reference to support your analysis.

Key Players

Review the points of view of the following people to obtain further insights on this assignment….

Preview:

The CEO of Southside HMO, which serves 495,000 members in the Eastern region of the United States, has received various complaints from plan holders, claiming that they do not receive quality healthcare services and that some of them are….

HSM 546 Patient Protection and Affordability Act Week 3

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Use the DeVry-Keller Online Library to find a research article (no older than 2009) related to the Patient Protection and Affordability Act. Discuss physician practice behaviors related to managed healthcare and the future of managed care under healthcare reform.

Your written paper should be 750 words, double-spaced, and in APA style. Your primary text and the journal or website research article must be used as references to support your analysis paper. Use at least three references.

Preview:

Enacted on March 3, 2010, the Patient Protection and Affordability Act enabled 95 percent of America’s legal population (32 million-50 million more Americans) to obtain healthcare insurance (Amadeo, 2018).  Also known as…

HSM 546 Pay-For-Performance Homework Assignment Week 5

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Go to the Centers for Medicare and Medicaid Services website CMS.gov

Click on one of the articles. Analyze pay for performance quality and incentives in hospitals, nursing homes, or provider offices and describe the performance standards and scoring methods.

Your written paper should be 750 words, double-spaced, and in APA style. Our primary text and the journal or website research article must be used as references to support your analysis paper. You must use at least three professional references. Include a link to the primary article selected for this assignment.

Preview:

Pay-for-performance pertains to initiatives that aim to improve the efficiency, quality, and the overall value of health care (Andrus, 2015).  Also known as pay-for-quality,…

HSM 546 Aetna Insurance Course Group Project

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Objectives

Your Course Project gives you the opportunity to select a managed healthcare organization or an integrated healthcare delivery system that currently exists within our healthcare industry to analyze the positive and negative aspects of the integrated delivery system or healthcare organization. In a small group assigned by the professor, you will work and collaborate to create a digital project that involves building a narrative/video presentation to demonstrate your understanding of the project.

Your professor will divide you up into teams of three to four. Research which managed healthcare organization or integrated healthcare delivery system you wish to choose for your Course Project. Utilizing an online collaboration tool, such as Cisco Spark, Google Hangout, Skype, and so forth, meet with your team and discuss which topic you will use for your Course Project. Make sure that you are able to find adequate references for your project (i.e., a minimum of eight scholarly or primary source references). Your textbook serves as one reference. The final Course Project, due in Week 7, will be a group presentation utilizing PowerPoint or Prezi and must include audio. All members of the group must present part of the project. Your group may choose to use another type of presentation software, but it must be approved first by the professor.

Milestones

The following deliverables are due accordingly.

Team Deliverables

Week 2: Topic Selection

One member of the group will submit a Word document with the names of all of the group members, the name of the health delivery system or managed care organization that you’ve chosen, and a screen shot of whichever online collaboration tool you are using that proves all members were part of the discussion and decision-making process.

Before you submit your course project topic, make sure you are able to find at least three primary sources with enough information meeting the requirements in both length and in comparing key indicators of the U.S. healthcare system to your chosen managed healthcare organization or integrated delivery system.

As you conduct your research, seek out quality primary sources for writing your paper. Don’t overlook the Keller Library as an important source of information for your paper. Remember: a minimum of eight scholarly references, including our text, are required (using APA style and format).

Week 3: Team Outline

One member of the group will submit a Word document with the names of all of the group members, a content outline indicating how you plan to address key elements of the project, and a screenshot of the online collaboration tool you are using that proves all members were part of the discussion and decision-making process.

The outline will help you create the narrative for your PowerPoint Presentation (due in Week 4) and should include what you will potentially cover and the references you intend to use.

Preview:

To work on the project, each team member will conduct their own research on the topic of Aetna Systems.  Each week, the team will meet, discuss, and…

Week 4: PowerPoint Presentation and Peer Review Discussion

PowerPoint Presentation

First, submit your PowerPoint Presentation to the Week 4 Course Project: Milestone and Submission page.

Next, one member of the group will submit the Course Project Presentation in the Week 4 Course Project Peer Review discussion.

Peer Review Discussion

Everyone is required to view two presentations other than their own and provide positive and constructive feedback. Remember, they must still be quality posts. Simply stating, “Nice job, I agree,” is not sufficient.

Examples of quality posts include

  • providing additional information to the discussion;
  • elaborating on previous comments from others;
  • presenting explanations of concepts or methods to help fellow students,
  • presenting reasons for or against a topic in a persuasive fashion,
  • sharing your personal experiences that relate to the topic, and
  • providing a URL and explanation for an area you researched on the Internet.

Week 7: Group Presentation

Group Presentation

The group presentation must utilize PowerPoint or Prezi and must include audio. All members of the group must present part of the project. Your group may choose to use another type of presentation software but it must be approved by the professor first. The video should be 10–15 minutes in length and include a bibliography for all references.

HSM 546 Aetna Course Project Individual Paper Week 7

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Your Course Project Individual paper is due this week. As a reminder, the length of the final paper should be approximately 8–10 pages, and it should be double-spaced in MS Word using APA format.  Your paper should be on the same topic as your group presentation and is where you will get the info to put together the presentation.  Each team member writes their own paper, but you use the collective knowledge to do the presentation.

Preview:

Aetna: The Positive and Negative Aspects of Managed Care

Managed care refers to a “a health care delivery system organized to manage cost, utilization, and quality” (Medicaid, 2014). Managed care health plans are a form of health insurance that have contracts with medical facilities and healthcare providers to…

HSM 546 Health Insurance Management Discussions Week 1-7 All Posts 931 Pages

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HSM 546 Managed Care and Current Trends and Quality and Access Discussions Week 1 All Posts 141 Pages

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HSM 546 Managed Care and Current Trends Discussions 1 Week 1 All Posts 70 Pages

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Let’s begin by understanding how our text defines managed care. In your own words, define managed care and discuss how managed care will impact healthcare delivery under healthcare reform.

What are some examples of early HMO prototypes? Why were they developed?  With the preponderance of HMOs today, has the stance of the AMA changed? If so, how?  Do you think that HMOs are effective at controlling costs?  How about quality of care?  It seems that HMOs were developed in a large part to benefit physicians with steady income.  What was in it for the consumer of health care?  HMOs of all configurations are touted as containing costs while delivering equality care.  How is this possible?  How are costs held down while still delivering what the patient needs?

We know that insurance plans are a good recruitment and retention perk today.  What was the point in the early formative days?  What was the benefit to the employer providing health care benefits?…

HSM 546 Quality and Access Discussions 2 Week 1 All Posts 71 Pages

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We all have our own perspective as it pertains to what quality healthcare should consist of. In this discussion, identify what is a priority for you when it comes to healthcare. What is a must have? In your own words, explain the importance of why managed care plans must provide quality healthcare.

What are some issues that are affecting access to managed care? How would access issues affect quality or care?  How do you see HMOs affecting access related to issues such as rural settings, cultural differences, and trust?  Medicaid has historically reimbursed physicians at a low rate for care provided.  In some areas, physicians have begun to refuse new patients with Medicaid as a payer source. How do you think an HMO model for Medicaid patients would affect payment levels?  How does the referral process work?  Who is responsible for approving or disapproving requested care?

What do you know about case management (or disease management)?  It would seem that it is patient-centric (to coin a phrase) but is it really cost effective?  We may be able to keep patients healthier in the short term but is it really saving money in the long term?…

HSM 546 Health Maintenance Organizations and Governance of Managed Care Organizations Discussions Week 2 All Posts 144 Pages

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HSM 546 Health Maintenance Organizations Discussions 1 Week 2 All Posts 72 Pages

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In your own words, explain open- and closed-panel health maintenance organizations (HMOs) and the continuum of managed care. Share an experience about either panel HMO or the continuum of managed care.

What are examples of open- and closed-panel HMO plans?  What do you think is an advantage and a disadvantage to each type of HMO from the patient’s point of view?  How about from the HMOs vantage point?  How does each type of HMO affect how the patient accesses care?  Which has more freedom of choice?  What are the advantages and disadvantages of closed- and open-panel HMO plans?  One of the goals of HMOs is to contain costs in health care.  How do you think the required copayments affect patients’ ability or willingness to seek care?  Does it delay care until conditions are more severe, driving up the overall cost of care?…

HSM 546 Governance of Managed Care Organizations Discussions 2 Week 2 All Posts 72 Pages

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Based on our textbook, Essentials of Managed Health Care, let’s include in this discussion how the board of directors came into existence and its relevance (see Chapter 3). In your own words, describe the makeup and function of the board of directors in managed care plans.

What agencies oversee regulation of HMO plans?  What would be the process to file a complaint against an HMO in your state? What is the role of the state in the insurance industry?  Are there specific requirements for HMO models?  What do you think the advantages, if any, would be to move oversight to the federal level in terms of uniformity?  How do the states vary in their oversight?  What are the most important functions of the board of directors? Defend your answer….

HSM 546 Provider Networks and Federal Regulations Discussions Week 3 All Posts 121 Pages

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HSM 546 Provider Networks Discussions 1 Week 3 All Posts 55 Pages

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Let’s start by defining the various contracting approaches as mentioned in our textbook, Essentials of Managed Health Care. In your own words, explain contracting approaches for physicians and hospitals under managed care plans.

What are the benefits of contracting from the health plan’s point of view? What are the benefits to the providers?  What are some ways to change physician behaviors in relationship to risk management?  What is the National Practitioner Data Bank? What do HMOs use it for?  Why is network maintenance important from the business point of view?  What behavior on the part of a payer would likely result in negative provider behavior? What policies and procedures could be used to deal with unacceptable provider behavior?…

HSM 546 Federal Regulations Discussions 2 Week 3 All Posts 66 Pages

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As you prepare your responses, include when and why regulation shifted from the state to the federal level. In your own words, discuss the federal regulations and acts to regulate health maintenance organization plans.

What are the provisions of the ACA and how do they apply to managed care?  What do you think has had the greatest impact on health care, increased enrollment or more services at lower costs?  Considering plans are now required to spend more on sicker patients, are unable to deny preexisting conditions, and are also required to cover more preventative care, how do you see this affecting the overall cost of health care?  Which provision do you think has had the greatest impact on access to health care?  With the access to health insurance, health care providers have been overwhelmed with patients and as you also pointed out, those that had been uninsured are presenting with more severe health care issues.  Any ideas on how to solve that problem?…

HSM 546 Provider Payment and Claims and Benefits Discussions Week 4 All Posts 135 Pages

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HSM 546 Provider Payment Discussions 1 Week 4 All Posts 89 Pages

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This is a two-part question worth a total of 20 points.

Part 1: Provider Payment (10 points)

Before we talk about the challenges, let’s first define P4P. What does our text say about P4P? Discuss the challenges and benefits of pay for performance under managed care plans.

Part 2: Claims and Benefits (10 points)

What are the current challenges of claims capabilities, including ICD-10-CM?

What are the key elements in most capitation programs in open-panel health maintenance organizations? What are the financial incentives to the provider under capitation?  Are there any?  Are there any negative aspects to using telehealth in MCOs?  What are the benefits to the patient?  What are some of the challenges for the provider of meeting the requirements in a P4P program?  Once the standards are determined, what additional challenges do the providers have to meet the requirements for payment in a P4P program?…

HSM 546 PowerPoint Presentation and Peer Review Discussions 2 Week 4 All Posts 46 Pages

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One member of the group will submit the Course Project PowerPoint Presentation to the Week 4 Course Project Peer Review discussion topic. Everyone is required to review two presentations (other than their own), and provide positive and constructive feedback.

Remember that the posts must still be quality posts. Simply responding by saying “Nice job” or “I agree” does not constitute a quality post.

Quality posts

  • provide additional information to the discussion;
  • elaborate on previous comments made by others;
  • present explanation of concepts to assist fellow students;
  • present “for” or “against” a topic in an appropriate and respectful way;
  • share personal experiences that contribute to the topic; and
  • provide a scholarly URL with explanation for an area you researched on the Internet.

HSM 546 Legal Issues and Fraud and Abuse Discussions Week 5 All Posts 144 Pages

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HSM 546 Legal Issues Discussions 1 Week 5 All Posts 73 Pages

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What are the clauses and provisions that should be included in provider contracts?

Class, as we have been discussing, HMOs provide care through arrangements with providers, clinics, hospitals and other types of facilities. A contract is used to make the relationships formal. A well-written contract can promote a positive relationship between parties as well as providing protection for both sides.
What are the differences between a letter of intent and an agreement? What is the purpose of each?  In the health care realm, what items do you think would be important to include in a letter of intent?  If you were drawing up a letter of intent, what would you include?  How does HIPAA affect how MCOs operate in individual and group insurance markets?

HSM 546 Fraud and Abuse Discussions 2 Week 5 All Posts 71 Pages

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What steps should be taken to mitigate exposure and liability when the federal government shows up to audit a healthcare organization? Why do you think people risk engaging in fraud and abuse actions regardless of the policies in place (or possible consequences levied) if found guilty of such actions?

What are the differences between health care fraud and abuse? Give an example of each.  What is an example of falsification of records that would constitute abuse?  What is the role of the Office of Inspector General in the investigation of healthcare fraud?  What are some of the challenges and forces that complicate effective health care fraud and abuse control? What are some of the ways to address those challenges?

HSM 546 Utilization Review and Medicare Advantage Plans and Medicaid Plans Discussions Week 6 All Posts 141 Pages

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HSM 546 Utilization Review Discussions 1 Week 6 All Posts 68 Pages

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Describe the three categories of utilization review and explain why utilization review is the framework for utilization management. Let’s include in this conversation how basic utilization has evolved over the years.

How has utilization management has changed over the years, and why has it changed?  What are the basic utilization management techniques and the basic measurement of utilization?

Do you think UM automatically leads to lowered health care costs?  What potential conflicts do you see between UM and patient care?  Do you think UM is cost effective?  Does reducing inappropriate care have an effect on costs overall?

HSM 546 Medicare Advantage Plans and Medicaid Plans Discussions 2 Week 6 All Posts 73 Pages

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Compare and contrast Medicare Advantage plans and Medicaid plans. What are some of the distinctive differences as defined by Kongstvedt?

Class, do any of your states have similar requirements, or other requirements for licensing and registration?  What were the impact of the Medicare Modernization Act and the Patient Protection and Affordable Care Act on Medicare managed care plans?  Class, how have Medicare Advantage plans have evolved over the years? What do Medicare Advantage plans look like today?  What are the eligibility requirements to participate in a Medicare Advantage plan?  What kinds of consumer rights and protections are available to enrollees, or prospective enrollees, of Medicare Advantage plans?

HSM 546 State Regulations of Managed Care Plans and Federal Regulations of Managed Care Plans Discussions Week 7 All Posts 106 Pages

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HSM 546 State Regulations of Managed Care Plans Discussions 1 Week 7 All Posts 58 Pages Keller

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Class, let’s begin by discussing HIPAA. How do state regulations apply to HIPAA?  How do state laws govern the insurance marketplace, including the NAIC models?  How does ERISA preemption of state insurance laws and mandates affect payers and health plans? What about the fiduciary responsibility of ERISA; what does that imply?  Why would it be problematic for an employee benefit plan to also be an insurance company, bank, trust,  or investment company?

Has anyone in the class had to use Cobra coverage?  If so, what did you think of the coverage and cost?

HSM 546 Federal Regulations of Managed Care Plans Discussions 2 Week 7 All Posts 48 Pages

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Discuss the federal agencies that are responsible for the oversight of HMOs, and discuss when federal regulations or state regulations would apply to situations, such as HIPAA privacy standards.

According to the McCarran-Ferguson Act and the Health Maintenance Organization (HMO) Act, oversight of health insurance regulation for HMOs is left to the states. Based on your understanding of HMO oversight, do you believe the states should have such authority?

Class, how might HIPAA privacy requirements differ from state laws regarding the confidentiality of health information? If there is a difference, which one would take precedence?  Class, do you think regulating health care at the state level is efficient?  Does it provide the same levels of access to all Americans across the board?  How did the enactment of the HMO Act change the federal government’s responsibility for the oversight of HMOs?

HSM 546 Final Exam Health Insurance Management

A+

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(COs A, B, and D) Capitation is defined as _____.

Prepayment for services on a fixed, per member, per month basis

Fee-for-service, including withhold provisions

Performance based compensation system

Stop-loss reinsurance provisions

(COs A, B, and D) Which federal law has established specific, enforceable regulations to help ensure the privacy and confidentiality of individual health information?

OCR

HEDIS
HIPPA
EMTALA

(COs A, B, D and G) The fee for service (FFS) payment method may encourage _____.

Unbundling

Upcoding

Churning

All of the above

(COs A, B, C, D, E, F, G, & H) What is disease management?

Disease management refers to a system of coordinated health care communications and interventions for populations with conditions where…

COs A, B, C, D, E, F, G, & H) Explain what integrated delivery systems are, and provide some examples.

The concept of integrated delivery system involves placing all required levels of care within a single integrated…

(TCOs A, B, and D) Managed health care is best described as _____.

An insurance company that provides health services

A broad and constantly changing array of health plans that attempt to manage both cost and quality of care

An inexpensive form of payment for health services

(TCOs A, B, and D) Which type of case is least likely to benefit from case management?

Cancer

AIDS

Normal vaginal delivery

All of the above

(TCOs A, B, and D) Which of the following organizations has developed accreditation programs for managed care organizations?

NCQA

URAC

AAAHC

A and B

All of the above

(TCOs A, B, and D) The integral components of managed care are _____.

Wellness and prevention

Primary-care orientation

Utilization management

Wellness, prevention, and utilization management

All of the above

(TCOs A, B, and D) The purpose of ERISA is to _____.

Ensure that all individuals receive emergency medical care, regardless of their ability to pay for services

Ensure the continuation of coverage for individuals who may lose health insurance due to termination of their employment

To protect workers in employee insurance plans and their beneficiaries by the requirement of disclosure and reporting financial and other information to workers and their beneficiaries

All of the above

(TCOs A, B, and D) Fees for services are generally determined by using _____.

Quality indicator measures

HMO insurance fee schedules

HMO insurance fee schedules

The type of services provided

(TCO A) Describe the key steps in developing a modern quality management program.

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The first step to developing a modern quality management program is to identify the scope of the problem and estimate the benefits of…

(TCO H) Explain what a gag clause is, and why it is important in managed care plans.

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The gag clause is a legislation clause that prohibits physicians from frankly and openly discussing all treatment options – whether covered or…

(TCO C) Discuss the purpose of the Patient Protection and Affordable Care Act.

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The Patient Protection and Affordable Care Act, which was signed into law on March 2010, was intended to extend coverage to the millions of Americans who are…

(TCO E) Describe the role of state government in the regulation of managed care.

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While the federal government regulates managed care and health plans sponsored by private-sector employers, the state governments regulate the….

(TCO F) Discuss the role of the primary care physician in utilization management.

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The primary care physicians play a big role in utilization management because they can greatly influence how much care a patient receives. Since a primary care…

(COs A, B, C, D, E, F, G, & H) What is disease management?

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Disease management refers to a system of coordinated health care communications and interventions for populations with conditions where…

(COs A, B, C, D, E, F, G, & H) Explain what integrated delivery systems are, and provide some examples.

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The concept of integrated delivery system involves placing all required levels of care within a single integrated…

(TCO H) Discuss the three broad types of structure for managed care plans.

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The three broad types of structure for managed care plans are health maintenance organizations (HMOs), Point of Service (PS), and…

(TCO C) Explain the relationship between provider networks, managed care plans, and plan members. What is the importance of this relationship?

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Managed care plans are a type of health insurance, which enters into contract with medical facilities and healthcare providers…

(COs D and E) Explain the HMO Act of 1973 and how the act changed the government’s role in managed care.

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The HMO Act of 1973 is a US federal law enacted under President Richard Nixon’s administration. It intends to encourage…

(COs G and H) Discuss the categories that fall under the state requirements for the health insurance market, and the laws that govern health insurance markets. What is it and why is it important?

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The categories that fall under the state requirements for the health insurance market are HMOs, PPOs, and POS plans. HMOs…