Chapter 13: Texas Statutes and Rules Pertinent to Health Maintenance Organizations (HMOs) Flashcards
______ finance health care for their members primarily on a prepaid basis. They also organize and deliver the services.
Health Maintenance Organizations (HMOs)
Subscribers to a(n) ______ pay a fixed periodic fee (usually monthly) and receive in return a broad range of health services from routine doctor visits to emergency and hospital care.
Health Maintenance Organization (HMO)
In Texas, if the medically necessary covered service is not available through network physicians or providers (and within a reasonable period of time), every ______ must allow referral to a non-network physician or provider. The ______ must fully reimburse the non-network physician or provider at the usual or customary or an agree upon rate.
Health Maintenance Organization (HMO)
______ are a specific dollar amount or a percentage of the cost of care that must be paid by the member.
Copayments
Most private insurance plans contain both ______ (expressed in dollar amounts) and ______ provisions (expressed in a percentage) to indicate the financial participation required of an insured.
- Deductibles
2. Coinsurance
While HMOs usually contain a(n) ______, they do not use ______ and ______ provisions.
- Copayment
- Deductibles
- Coinsurance
The theory of the ______ is that you pay a periodic fee for membership then as a member you will receive all services necessary from the member physicians and hospitals.
Health Maintenance Organization (HMO)
______ health insurance plans offer a broad coverage of medical expenses from any provider chosen by the insured. These plans are sometimes called ______ because they provide benefits without requiring the insured to satisfy a deductible.
- Indemnity
2. First-Dollar Insurance
Initially the member chooses a(n) ______ or ______. If the member needs the attention of a specialist, this individual must refer the member.
- Primary Care Physician (PCP)
2. Gatekeeper
A(n) ______ HMO differs from a(n) ______ HMO in that it contracts with two more independent groups of physicians to provide medical services to its subscribers.
- Network-Model
2. Group-Model
Texas HMOs must provide each enrollee ______ that includes the following:
- The HMO’s name, address, and phone number.
- A schedule of benefits, copayments, and deductibles.
- Policy cancellation and nonrenewal provisions.
Evidence of Coverage
Texas HMOs may not charge for immunizations for children from birth through age of ______.
6
In order to establish or operate a health maintenance organization (HMO) in Texas, a(n) ______ from the Commissioner is required.
Certificate of Authority
Most HMOs operate exclusively through a(n) ______ system. Each member of the group pays a premium, whether or not the person uses the services of the HMO.
Group Enrollment
Most ______ either operate their own hospitals and clinics, that are staffed by health care professionals who are employed by the ______, or enter into volume discount arrangements with hospitals and providers as well as agreements with physicians to provide service on a prearranged per capita basis (called ______).
- HMOs
- HMO
- Capitation
The ______ may issue investment rules of HMOs to ensure that enrollees have sufficient access to health care providers as well as set minimum physician-patient ratios, mileage requirements for primary and specialty care, maximum travel time, and maximum waiting times for obtaining appointments.
Commissioner
HMO policies must contain a statement that specifies the following permissible grounds for policy ______ or ______:
- Nonpayment of amounts due.
- Fraud in the use of services or facilities.
- Failure to meet eligibly requirements - coverage may be canceled ______.
- Misconduct that is detrimental to safe plan operations or the delivery of services - coverage may be canceled ______.
- Failure for the enrollee and a plan physician to establish a satisfactory relationship.
- When the subscriber does not reside or work in the HMO service area.
- Cancellation
- Nonrenewal
- Immediately
- Immediately
When a policy is cancelled for nonpayment of premium, the insurer is required to provide a(n) ______ ______ to the insured. If a policy is cancelled for fraud, the notice must be at least ______.
- 30-Day
- Written Notice
- 15 Days
______ are designed to finance health care for members on a prepaid basis.
Health Maintenance Organizations (HMOs)
Persons covered by an HMO contract are called ______.
Subscribers
Subscribers pay a(n) ______, which is payable regardless of the services being utilized.
Fixed Periodic Fee
______ typically operate through a group enrollment system, where each member of the group pays a premium.
Health Maintenance Organizations (HMOs)
HMOs encourage ______.
Preventive Care
If medically necessary services are not covered through network physicians or providers, an HMO must allow ______ and fully ______ referred non-network physicians or providers.
- Referrals
2. Reimburse
______ are specific dollar amounts or percentages of cost of care that must be paid by a member.
Copayments
______ and ______ are participation requirements that must be met by the insured before insurance pays.
- Deductibles
2. Coinsurance
______ are expressed in dollar amounts; ______ are expressed as a percentage.
- Deductibles
2. Copayments
______ refers to the payment of a periodic fee for membership, which then allows the member to receive the services of member physicians and hospitals.
Prepaid Services
______ plans offer a broad coverage for the medical expenses of any provider the insured chooses.
Indemnity Health Insurance
As an enrollee in an HMO, a subscriber must choose a(n) ______, which is the person the subscriber must go to for his or her initial and primary care.
Primary Care Physician (PCP)
Enrollees in an HMO must have a referral from the ______ in order to see a(n) ______.
- Primary Care Physician (PCP)
2. Specialist
______ HMOs contract with independent groups of physicians to provide medical services to subscribes.
Network-Model
______ must include the HMO’s name, address, phone number, schedule of benefits, copayments, deductibles, and policy cancellation and nonrenewal provisions.
Evidence of Coverage
HMOs cannot charge for the ______ of children younger than 6 years old, unless a small employer health benefit plan covers children’s ______.
Immunization(s)
An HMO ______ must include the schedule of charges to be used in the first year of operation.
Certificate of Authority
To cancel an HMO contract due to nonpayment of premium, a(n) ______ advance written notice must be sent to the insured.
30 Days’
To cancel an HMO contract due to fraud or material misrepresentation, ______ advance written notice is required.
15 Days’
HMOs are prohibited from permitting the use of deceptive ______ or using untrue or misleading ______.
- Evidence of Coverage
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