Chapter 5 Contd

Question 1

Unlike basic medical expense plans these policies carry deductibles xo insurance requirement and large benefit maximums

Answer 1

Major medical policies

Question 2

Comprehensive coverage for hospital expenses, catastrophic medical expense protection and benefits for prolonged injury or illness under these

Answer 2

Major medical policies

Question 3

Two common types of major medical policies available

Answer 3

Supplement major medical policies and comprehensive major medical policies

Question 4

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

Answer 4

Employers are no longer forced to offer hmo plans

Question 5

Main goal focus of hmo

Answer 5

Preventative care

Question 6

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

Answer 6

Early detection through regular checkups

Question 7

Not covered by health maintenance organizations

Immunizations
Routine physicals
Well baby care
Elective services

Answer 7

Elective services

Question 8

How are hmo territories typically divided

Geographic areas
Type of physician services available
Community rating system

Answer 8

Geographic areas

Question 9

Which of following is term for specific dollar amount that must be paid by hmo member for service

Deductible
Premium
Cost share
Copayment

Answer 9

Copayment

Question 10

Usually no deductible required under hmo plans true or false

Answer 10

True

Question 11

Which is not provided by hmo

Financing
Patient care
Services
Reimbursement

Answer 11

Reimbursement

Question 12

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

Answer 12

Contracting with ins companies

Question 13

Hmo operate on a what basis

Flat amount each month attributed to each member

Answer 13

Prepaid captivates basis

Question 14

When individual becomes a member of hmo they will chose their primary care physician or

Answer 14

Gatekeeper

Question 15

Who chooses primary care physician in hmo

Insurer
Referral physician
Individual member

Answer 15

Individual member

Question 16

Gatekeeper of an hmo helps

Control specialist costs
Determine who will be allowed to enroll in hmo program
Prevent double coverage

Answer 16

Control specialist costs

Question 17

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

Answer 17

Primary care physician refers member

Question 18

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

Answer 18

Member of hmo can rec care in or out of the hmo service area but care is preferred in the service area

Question 19

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

Answer 19

Agree to follow ppo standards and charge the appropriate fees

Question 20

Ppo =

Answer 20

Preferred provider organizations

Question 21

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

Answer 21

Ppo will pay reduced benefits

Question 22

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

Answer 22

Its goal is to channel patients to providers that discount services

Question 23

Ppo differ from hmo in two ways: first

Do not provide care on prepaid basis but physicians paid

Answer 23

Fee for service

Question 24

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

Answer 24

Have contracts with the ppo

Question 25

Unlike hmos pops allow more flexibility between in network and out network providers

Answer 25

In exchange for a higher premium

Question 26

Group of physicians and hospitals that contract with employers insurers or third party organizations to provide medical care services at a reduced fee

Answer 26

Ppo

Question 27

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

Answer 27

Care can be provided outside of service area

Question 28

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

Answer 28

Preferred provider organization

Question 29

Merely combination of hmo and ppo

Answer 29

Point of service plan

Question 30

If health care plan has characteristics of an hmo and ppo is is

Fsa
Pos
HIPAA
Met

Answer 30

Pos

Question 31

When are practicing providers compensated on fee for service basis

Ppo
Hmo
Blue cross blue shield
open panel

Answer 31

Ppo contract on fee for service basis

Question 32

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

Answer 32

Preferrred provider organization

If they choose to go to provider outside preferred provider they have to pay part of cost of service