Chapter 5 Contd Flashcards
Unlike basic medical expense plans these policies carry deductibles xo insurance requirement and large benefit maximums
Major medical policies
Comprehensive coverage for hospital expenses, catastrophic medical expense protection and benefits for prolonged injury or illness under these
Major medical policies
Two common types of major medical policies available
Supplement major medical policies and comprehensive major medical policies
HMO act of 1973 required employers to offer hmo plan as alternative to regular health plans if company had more than 25 employees. How has this changed?
Minimum number of employees has increased
Source of funding has changed
Employers are no longer forced to offer hmo plans
Employers are no longer forced to offer hmo plans
Main goal focus of hmo
Preventative care
What is goal of hmo
Providing health services close to home
Early detection through regular checkups
Providing free health services
Limiting deductibles and coinsurance to reduce costs
Early detection through regular checkups
Not covered by health maintenance organizations
Immunizations
Routine physicals
Well baby care
Elective services
Elective services
How are hmo territories typically divided
Geographic areas
Type of physician services available
Community rating system
Geographic areas
Which of following is term for specific dollar amount that must be paid by hmo member for service
Deductible
Premium
Cost share
Copayment
Copayment
Usually no deductible required under hmo plans true or false
True
Which is not provided by hmo
Financing
Patient care
Services
Reimbursement
Reimbursement
Which of following is not characteristic or a services of an hmo plan
Providing free annual checkups
Encouraging early treatment
Providing care on an outpatient basis
Contracting with ins companies
Contracting with ins companies
Hmo operate on a what basis
Flat amount each month attributed to each member
Prepaid captivates basis
When individual becomes a member of hmo they will chose their primary care physician or
Gatekeeper
Who chooses primary care physician in hmo
Insurer
Referral physician
Individual member
Individual member
Gatekeeper of an hmo helps
Control specialist costs
Determine who will be allowed to enroll in hmo program
Prevent double coverage
Control specialist costs
How does member of hmo see specialist
HMOs do not cover specialists
Member is allowed to choose his or her own specialist
Primary care physician refers member
Primary care physician refers member
How is emergency care covered for a member of an hmo
HMOs have salaried member physicians but they dont cover emergency care
Hmo emergency specialist will cover the patient
Member of an hmo can rec care in or out of the hmo service area but care is preferred in the service area
Member of hmo may rec care at any emergency facility at the same cost as if in his or her own service area
Member of hmo can rec care in or out of the hmo service area but care is preferred in the service area
How can new physician be added to ppo approved list
Agree to follow ppo standards and charge appropriate fees
Fill out appropriate paperwork and wait 12 month pre cert period
Pay annual fee for being on the ppo list
Agree to follow ppo standards and charge the appropriate fees
Ppo =
Preferred provider organizations
An employee becomes insured under a ppo plan provided by employer. If insured decides to go to physician who is not a ppo provider which will happen
Insured will be required to pay higher deductible
Ppo will pay same benefits as if insured had seen ppo physician
Ppo will pay reduced benefits
Ppo will pay reduced benefits
Which of following is true of ppo
Claim forms are completed by members on each claim
No copayment fees are involved
Its goal is to channel patients to providers that discount services
Its goal is to channel patients to providers that discount services
Ppo differ from hmo in two ways: first
Do not provide care on prepaid basis but physicians paid
Fee for service
Pops differ from hmo in two ways. Do not provide care on prepaid basis but physicians are paid a fee for service. Secondly subscribers are not required to use physicians or facilities that
Have contracts with the ppo
Unlike hmos pops allow more flexibility between in network and out network providers
In exchange for a higher premium
Group of physicians and hospitals that contract with employers insurers or third party organizations to provide medical care services at a reduced fee
Ppo
Which is true regarding inpatient hospital care for hmo members
Services for treatment of mental disorders are unlimited
Inpatient hospital care is not part of hmo services
Care can be provided outside of service area
Care can only be provided in service area
Care can be provided outside of service area
When health care insurerers negotiate contracts wit health care providers or physicians to provide health care services for subscribers at favorable cost is it called
Managed care
Indemnity plans
Point of service plans
Preferred provider organization
Preferred provider organization
Merely combination of hmo and ppo
Point of service plan
If health care plan has characteristics of an hmo and ppo is is
Fsa
Pos
HIPAA
Met
Pos
When are practicing providers compensated on fee for service basis
Ppo
Hmo
Blue cross blue shield
open panel
Ppo contract on fee for service basis
When health care insurers negotiate contracts with health care providers or physicians to provider health care services for subscribers at favorable cost it is called
Managed care
Indemnity plans
Point of service plans
Preferred provider organization
Preferrred provider organization
If they choose to go to provider outside preferred provider they have to pay part of cost of service
