Chapter 13: Texas Statutes and Rules Pertinent to Health Maintenance Organizations (HMOs)

Question 1

______ finance health care for their members primarily on a prepaid basis. They also organize and deliver the services.

Answer 1

Health Maintenance Organizations (HMOs)

Question 2

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.

Answer 2

Health Maintenance Organization (HMO)

Question 3

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.

Answer 3

Health Maintenance Organization (HMO)

Question 4

______ are a specific dollar amount or a percentage of the cost of care that must be paid by the member.

Answer 4

Copayments

Question 5

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.

Answer 5

1. Deductibles

2. Coinsurance

Question 6

While HMOs usually contain a(n) ______, they do not use ______ and ______ provisions.

Answer 6

1. Copayment
2. Deductibles
3. Coinsurance

Question 7

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.

Answer 7

Health Maintenance Organization (HMO)

Question 8

______ 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.

Answer 8

1. Indemnity

2. First-Dollar Insurance

Question 9

Initially the member chooses a(n) ______ or ______. If the member needs the attention of a specialist, this individual must refer the member.

Answer 9

1. Primary Care Physician (PCP)

2. Gatekeeper

Question 10

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.

Answer 10

1. Network-Model

2. Group-Model

Question 11

Texas HMOs must provide each enrollee ______ that includes the following:

1. The HMO’s name, address, and phone number.
2. A schedule of benefits, copayments, and deductibles.
3. Policy cancellation and nonrenewal provisions.

Answer 11

Evidence of Coverage

Question 12

Texas HMOs may not charge for immunizations for children from birth through age of ______.

Answer 12

6

Question 13

In order to establish or operate a health maintenance organization (HMO) in Texas, a(n) ______ from the Commissioner is required.

Answer 13

Certificate of Authority

Question 14

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.

Answer 14

Group Enrollment

Question 15

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 ______).

Answer 15

1. HMOs
2. HMO
3. Capitation

Question 16

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.

Answer 16

Commissioner

Question 17

HMO policies must contain a statement that specifies the following permissible grounds for policy ______ or ______:

1. Nonpayment of amounts due.
2. Fraud in the use of services or facilities.
3. Failure to meet eligibly requirements - coverage may be canceled ______.
4. Misconduct that is detrimental to safe plan operations or the delivery of services - coverage may be canceled ______.
5. Failure for the enrollee and a plan physician to establish a satisfactory relationship.
6. When the subscriber does not reside or work in the HMO service area.

Answer 17

1. Cancellation
2. Nonrenewal
3. Immediately
4. Immediately

Question 18

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 ______.

Answer 18

1. 30-Day
2. Written Notice
3. 15 Days

Question 19

______ are designed to finance health care for members on a prepaid basis.

Answer 19

Health Maintenance Organizations (HMOs)

Question 20

Persons covered by an HMO contract are called ______.

Answer 20

Subscribers

Question 21

Subscribers pay a(n) ______, which is payable regardless of the services being utilized.

Answer 21

Fixed Periodic Fee

Question 22

______ typically operate through a group enrollment system, where each member of the group pays a premium.

Answer 22

Health Maintenance Organizations (HMOs)

Question 23

HMOs encourage ______.

Answer 23

Preventive Care

Question 24

If medically necessary services are not covered through network physicians or providers, an HMO must allow ______ and fully ______ referred non-network physicians or providers.

Answer 24

1. Referrals

2. Reimburse

Question 25

______ are specific dollar amounts or percentages of cost of care that must be paid by a member.

Answer 25

Copayments

Question 26

______ and ______ are participation requirements that must be met by the insured before insurance pays.

Answer 26

1. Deductibles

2. Coinsurance

Question 27

______ are expressed in dollar amounts; ______ are expressed as a percentage.

Answer 27

1. Deductibles

2. Copayments

Question 28

______ refers to the payment of a periodic fee for membership, which then allows the member to receive the services of member physicians and hospitals.

Answer 28

Prepaid Services

Question 29

______ plans offer a broad coverage for the medical expenses of any provider the insured chooses.

Answer 29

Indemnity Health Insurance

Question 30

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.

Answer 30

Primary Care Physician (PCP)

Question 31

Enrollees in an HMO must have a referral from the ______ in order to see a(n) ______.

Answer 31

1. Primary Care Physician (PCP)

2. Specialist

Question 32

______ HMOs contract with independent groups of physicians to provide medical services to subscribes.

Answer 32

Network-Model

Question 33

______ must include the HMO’s name, address, phone number, schedule of benefits, copayments, deductibles, and policy cancellation and nonrenewal provisions.

Answer 33

Evidence of Coverage

Question 34

HMOs cannot charge for the ______ of children younger than 6 years old, unless a small employer health benefit plan covers children’s ______.

Answer 34

Immunization(s)

Question 35

An HMO ______ must include the schedule of charges to be used in the first year of operation.

Answer 35

Certificate of Authority

Question 36

To cancel an HMO contract due to nonpayment of premium, a(n) ______ advance written notice must be sent to the insured.

Answer 36

30 Days’

Question 37

To cancel an HMO contract due to fraud or material misrepresentation, ______ advance written notice is required.

Answer 37

15 Days’

Question 38

HMOs are prohibited from permitting the use of deceptive ______ or using untrue or misleading ______.

Answer 38

1. Evidence of Coverage

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