chapter 3 managed health care

Question 1

ACCREDITATION

Answer 1

VOLUNTARY PROCESS THAT A HEALTH CARE FACILITY OR ORGANIZATION UNDERGOES TO DEMONSRTRATE THAT IT HAS MET STANDARDS BEYOND THOSE REQUIRED BY LAW

Question 2

ADVERSE SELECTION

Answer 2

COVERING MEMBERS WHO ARE SICKER THAN THE GENERAL POPULATION

Question 3

AMENDEMENT TO THE HMO ACT OF 1973

Answer 3

LEGISLATION THAT ALLOWED FEDERALLY QUALIFIED HMO’S TO PERMIT MEBERS TO OCCASIONALLY USE NOT HMO PHYSICIANS AND BE PARTIALLY REIMBURESED

Question 4

CAFETERIA PLAN

Answer 4

PROVIDES DIFFERENT HEALTH BENFIT PLANS AND EXTRA COVERAGE OPTIONS THRUGH AN INSURER OR THIRD PARTH ADMINISRATOR

Question 5

CAPITAATION

Answer 5

PROVIDER ACCEPTS PREESTABLISHED PAYMENTS FOR PROCIDING HEALTH CARE SERVICES TO ENROLLEES OVER A PERIOD OF TIME

Question 6

CASE MANAGER

Answer 6

SUBMITS WRITTEN CONFIMATION AUTHORIZING TREATMENT TO THE PROVIDER

Question 7

CLOSED PANEL HMO

Answer 7

HEALTH CARE IS PRIVIDED IN AN HMO OWNED CENTER OR SATELLITE CLINIC OR BY PROVIDERS WHO BELONG TO A SPECIALLY FORMED MEDICAL GROUP THAT SERVES THE HMO

Question 8

COMPETITIVE MEDICAL PLAN

Answer 8

HMO THAT MEETS FEDERAL ELIGIBILITY REQUIREMENTS FOR A MEDICARE RISK CONTRACT BUT IS NOT LICENSED AS A FEDERALLY QUALIFIED PLAN

Question 9

CONSUMER DIRECTED HEALTH PLAN

Answer 9

COSNSUMER DRIVEN HEALTH PLAN

Question 10

CUSTOMIZED SUB CAPITATION PLAN

Answer 10

MANAGED CARE PLAN IN WHICH HEALTH CARE EXPENSES ARE FUNDED BY INSURANCE COVERAGE THE INDIVIDUAL SELECTS ONE OF EACH TYPE OF PROVIDER TO CREATE A CUSTOMIZED NETWORK AND PAYS THE RESULTING CUSTOMIZED INSURANCE PREMIUM

Question 11

DIRECT CONTRACT MODEL HMO

Answer 11

CONTRACTED HEALTH CARE SERVICES DELIVERED TO SUBSCRIBE BY INDIVIDUAL PROVIDERS IN THE COMMUNITY

Question 12

ENROLLEES

Answer 12

ALSO CALLED COVERED LIVES EMPLOYEES AND DEPENDENTS WHO JOIN A MANAGED CARE PLAN

Question 13

EXCLUSIVE PROVIDER ORGANIZATION EPO

Answer 13

MANAGED CARE PLAN THA TPROVIDES BENFITAS TO SUBSCRTIBES IF THEY RECEIVE SERVICES FORM NETWORK PROVIDERS

Question 14

EXTERNAL QUALITY REVIEW ORGANIZATION

Answer 14

RESPONSIBLE FOR REVIEWING HEALTH CARE PROVIED BY MANAGED CARE ORGANIZATIONS

Question 15

FEDERALLY QUALIFIED HMO

Answer 15

CERTIFIED TO PROVIDE HEALTH CARE SERVICES AND MEDICARE AND MEDICAID ENROLLEES

Question 16

FEE FOR SERVICE

Answer 16

REIMBURSEMNET METHODOLOGY THAT INCREASES PAYMENT IF THE HEALTH CARE SERVICE FEES INCREASE

Question 17

FLEXIBLE BENEFIT PLAN

Answer 17

CAFETERIA PLAN

Question 18

FLEXIBLE SPENDING ACCOUNT FSA

Answer 18

TAX EXEMPT ACCOUNT OFFERED BY EMPLOYERS WITH ANY NUMBER OF EMPLOYEES WHICH INDIVIDUALS USE TO PAY HEALTH CARE BILLS

Question 19

GAG CLAUSE

Answer 19

PERVENTS PROVIDERWS FORM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS

Question 20

GATEKEEPER

Answer 20

PRIMARY CARE PROVIDER FOR ESSENTIIAL HEALTH CARE SERVICES AT THE LOWEST POSSIBLE COST

Question 21

GROUP MODLE HMO

Answer 21

CONTRACTED HEALT CARE SERVICES DELIVERED TO SUNSCRIBERS BY PARTICIPATING PROVIDERS

Question 22

GROUP PRACTICE WITHOUT WALLS

Answer 22

CONTRACT THAT ALLOWS PROVIDERS TO MAINTAIN THEOIR OWN OFFICES AND SHARE SERVICES

Question 23

HEALTH CARE RIMBURSEMENT ACCOUNT

Answer 23

USED TO PAY FOR HEALTH CARE EXPENNSES

Question 24

HEALTH MAINTENANCE ORGANIZATION HMO

Answer 24

RESPONSIBLE FOR PROVIDINGN HEALTH CARE SEVICES SUBSCRTIBERS IN A GIVEN GEOGRAPHIVCAL AREA

Question 25

HEALTH MAINTENCE ORGANIZATION ASSISTANCE ACT OF 1973

Answer 25

GRANTS AND LOANS TO DEVELOP HMOS A ONE THA THAS APPKIED OFR AND MET FEDERAL STANDAREDS

Question 26

HEALTH REIMBURSEMENT ARRANGEMENT

Answer 26

OFFERED BY EMPLOYERS WITH 50 OR MOREEMPLOYEES

Question 27

HEALTH SAVINGS ACCOUNT

Answer 27

FLEXIBLE SPENDING ACCOUNT

Question 28

HEALTH SAVINGS SECURITY ACCOUNT

Answer 28

FLEXIBLE SPENDING

Question 29

HEALTHCARE EFFECTIVENESS DATA ADN INFORMATION SET

Answer 29

STANDARDS TO ASSESS MANGED CARE SYSTEMS USING DATE ELEMENTS THAT ARE COLLEDCTED

Question 30

INDEPENDENT PRACTICE ASSOCIATION IPA HMO

Answer 30

INDIVIDUAL PRACTICE ASSOCIATION

Question 31

INDIVIDUAL PRACTICE ASSOCIATION

Answer 31

HMO WHERE CONTRACTED HEALTH SERVICES ARE DELIVERED TO SUBSCRIBES

Question 32

INTEGRATED DELIVERY SYSTEM

Answer 32

OFFER JOINT HEALTH CARE SERVICES TO SUBSCRIBERS

Question 33

INTEGRATEDE PROVIDER ORGANIZATION

Answer 33

MANAGTES THE DELIVERY OF HEALTH CARE SERVICES

Question 34

LEGISLATION

Answer 34

LAWS

Question 35

MANAGED CARE ORGANIZATION

Answer 35

RESPONSIBLE FOR HEALTH OF GROUP OF ENROLLEES

Question 36

MANAGED HEALTH CARE

Answer 36

COMBINES HEALTH CARE DELIVERY WITH THE FINACING OF SERVICES PROVIDED

Question 37

MANAGEMENT SERICE ORGANIZATION

Answer 37

OWNED BY PHYSICIANS OR HOSPITAL AND PROVIDES PRACTICE MANAGEMENT

Question 38

MANDATES

Answer 38

LAWS

Question 39

MEDICAL FOUNDATION

Answer 39

NONPROFIT ORGANIZATION THAT CONTRACTS WITH AND ACQUIRES THE CLINICAL AD BUSINESS ASSETS OF PHYSICIAN PRACTICES

Question 40

MEDICARE RISK PROGRAM

Answer 40

FEDERALLY QUALIFIED HMOS

Question 41

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

Answer 41

PRICATE NOT FOR PROFIT ORGANIZATION THAT ASSESSES THE QUALITY OF MANGANED CARE PLANS

Question 42

NETWORK MODEL HMO

Answer 42

HEALTH CARE SEVICES PROVIDED TO SUBSCRIBERS BY 2 OR MOR PHYSICIANS

Question 43

NETWORK PROVIDER

Answer 43

OTHER HEALTH CARE PRACTITIONER OR HEALTH CARE FACILITY UNDER A MANAGED CARE PLAN

Question 44

OFFICE OF MANAGED CARE

Answer 44

CMS AGTIOENCY THAT FACILITATES INNOVATION AND COMPETITION AMONG MEDICARE HMOS

Question 45

OPEN PANNEL HMO

Answer 45

INDIVIDUALS WHO ARE NOT EMPLOYEES OF THE HMO OR WHO DO NOT BELONG TO A SPECIALLY FORMED MEDICAL GROUP

Question 46

PHYSICSIAN INCENTIVE PLAN

Answer 46

MANAGED CARE PLANS THAT CONTRACT WITH MEDICARE OR MEDICAID TO DISCLOSE INFORMATION ABOUT PHYSICIAN INCENTIVE PLANS

Question 47

PHYSICIAN INCENTIVES

Answer 47

PAYMENTS MADE DIRECTLY OR INDIRECTLY TO HEALTH CARE PROVDIERS

Question 48

PHYSICIAN HOSPITAL ORGANIZATION PHO

Answer 48

PHYSICIAN GROUPS THA TOBTAIN MANAGED CARE PLAN CONTRACTS

Question 49

POINT OF SERVICE PLAN POS

Answer 49

DELIVES HEALTH CARE SERVICES USING BOTH MANAGED CARE NETWORK AND TRAITIONAL

Question 50

PREFERRED POVIDER HEALTH CARE ACT OF 1985

Answer 50

EASED RESTRICTIONS ON PREFERRED PROVIDER ORGANIZZATIONS

Question 51

PREFERRED PROVIDR ORGANIZATION

Answer 51

OTHER HEALTH CARE PRACTITONERS AND HOSPITALS THAT HAVE JOINED THOGETHER TO CONTRACT WHITH INSURANCE COMPANIES

Question 52

PRIMARY CARE PROVIDER PCP

Answer 52

SUPERVISING AND COORDINATING HEALTH CARE SERVICES FOR ENROLLEES AND PREAUTHORIZING REFERRALS

Question 53

QUALITY ASSESSMETN AND PERFORMANCE IMPROVEMENT

Answer 53

QUALITY ASSURANCE ACTIVITES ARE PERFORMED TO IMPROVDE THE FUNCTIONING PF MEDICARE ADVANTAGE ORGANIZTIONS

Question 54

QUALITY ASSURANCE PROGRAM

Answer 54

ACTIVITES THAT ASSESS THE QUALITY OF CARE PROVIDED IN A HEALTH CARE SETTING

Question 55

QUALITY IMPROVEMENT SYSTEM FOR MANGED CARE

Answer 55

ENSURE ACCOUNTABILITY PF MANAGED CARE PLANS IN TERMS OF OBJECTIVE

Question 56

REPORT CARD

Answer 56

DATA REGARDING A MANAGED CARE PLANS QUALITY

Question 57

RISK ADJUSTMENT

Answer 57

PAYMENTS TO HEALTH PLANS ACCOUNTING FOR DIFFERENCES IN EXPECTED HEATLH COST OF ENROLLEES

Question 58

RISK ADJUSTMENT MODEL

Answer 58

PAYMENTS TO HEALTH PLANS THAT DISPOROPORTIONATELY ATTRACT HIGHER RISK ENROLLEES

Question 59

RISK ADJUSTMENT PROGRAM

Answer 59

LESSENS OR ELIMINATES THE INFLUENCE OF RISK SELECTION

Question 60

RISK CONTRACT

Answer 60

ARRANGENT AMONG PROVIDERS TO PROVIDE CAPITATIED HEALTH CARE SERVICES

Question 61

RISK POOL

Answer 61

NUMBER OF PEOPLE ARE GROUPED FOR INSURANCE PURPOSES

Question 62

RISK TRANSER FORMULA

Answer 62

TRANSFERS FUNDS FROM HEALTH PLANS WITH RELATIVELU LOWER RISK OR ENROLLEES

Question 63

SECOND DURGICAL OPINION

Answer 63

EVALUATE THE NECESSITY OF SURGERY

Question 64

SELF REFERRAL

Answer 64

NON HMO PANEL SPECIALIST WITHOUT AN REFERRAL

Question 65

STAFF MODEL HMO

Answer 65

PROVIDED TO SUBSCRIBES BY PHSICIANS AND OTHER HEALTH CARE PRACTITIONERS

Question 66

STANDARDS

Answer 66

REQUIREMENTS

Question 67

SUB CAPTATION PAYMENT

Answer 67

PROVIDER IS PAID A FIXED AMOUNT PRER MONTH

Question 68

SUBSCRIBERS

Answer 68

PERSONS WHOS NAME IS INSURANCE POLICY IS ISSUED

Question 69

SURVERY

Answer 69

ACCREDIATION ORGAI=NIZT=ATIO

Question 70

TRIPLE OPTION PLAN

Answer 70

SINGLE INSURANCE PLAN OR AS A JOIN VENTURE

Question 71

UTILIZATION REVIEW ORGANIZATION

Answer 71

UTILIZATION MANAGEMENT PROGRAM

Question 72

MEDICARE RISK PROGRAMS

Answer 72

HMOS AND COMPETITICE MEDICLA PLANS THAT MEET SPECIFIED MEDICARE REQUIREMENTS

Question 73

GAG CLAUSES

Answer 73

PREVENTS PROVIDES FROM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS

Question 74

CONSUMER DIRECTED HEALTH PLANS

Answer 74

CONSUMER DRIVEN HEALTH PLAN