Health-Care Plans - Health Plan Design Alternatives

Question 1

6 different medical plans

Answer 1

1. Traditional HMO
2. Open-Access HMO
3. Traditional Fee-for-Service Plan
4. Exclusive Provider Plan
5. Preferred Provider Organization
6. Point-of-Service Plan

Question 2

Prepaid plans

Answer 2

pay medical service providers a fixed amount based on the number of people enrolled, regardless of services received

Question 3

Indemnity plans

Answer 3

reimburse the patient or the provider as medical expenses occur or afterward

Question 4

2 prepaid plans

Answer 4

1. Traditional HMO

2. Open-Access HMO

Question 5

4 Indemnity plans

Answer 5

1. traditional fee-for-service plan
2. exclusive provider plan
3. preferred provider organization
4. point-of-service plan

Question 6

Network

Answer 6

A specific group of doctors, hospitals, suppliers, and clinics who have contracted to provide services for an agreed rate.

Question 7

Which plan does not have a designated network?

Answer 7

Traditional fee-for-service plan

Question 8

Which plans do not include nonemergency services outside network?

Answer 8

1. traditional HMO

2. exclusive provider plan

Question 9

Preferred provider organization vs. point-of-service plan

Answer 9

Point-of-service plan has 3 or more levels of benefits, unlike the preferred provider organization with only 2.

Question 10

Fee-for-service plans, 4

Answer 10

• provide protection against health care expenses in the form of a cash benefit paid to the employee or directly to the health care provider after receiving health-care services
• pays benefits on a reimbursement basis
• may generally select any licensed physician, surgeon, or medical facility for treatment, and the insurer reimburses the participants after medical services are rendered
• generally do not rely on networks or health-care providers

Question 11

managed care plans

Answer 11

emphasize cost control by limiting an employee’s choice of doctors and hospitals

Question 12

3 common forms of managed care plans

Answer 12

1. HMOs
2. PPOs
3. POSs

Question 13

Health maintenance organization

Answer 13

prepaid medical services, in which a fixed periodic enrollment fee covers HMO members for all medically necessary services only if the services are delivered by health-care providers in the designated network and, approved by the HMO

Question 14

Open-access HMO

Answer 14

Will also have emergency care outside the network covered

Question 15

Primary care physicians

Answer 15

Designated by HMOs or required by member to choose one. They determine when patients need the care of specialists.

Question 16

3 ways types of HMOs differ

Answer 16

1. where service is rendered
2. how medical care is delivered
3. how contractual relationships between medical providers and the HMOs are structured

Question 17

Prepaid group practices

Answer 17

provide medical care for a set amount

Question 18

3 forms of group prepaid group practices

Answer 18

1. staff model HMOs
2. group model HMOs
3. network model HMOs

Question 19

staff model HMOs

Answer 19

Such groups own the medical facilities, and these organizations employ medical and support staff on these premises.

Question 20

group model HMOs

Answer 20

primarily use contracts with established practices of physicians that cover multiple specialties. Do not directly employ physicians but compensate them according to a pre-established schedule of fees for each service, or by setting monthly amounts per patient.

Question 21

Network model HMOs

Answer 21

Like group model HMOs, but contract with two or more independent practices of physicians and compensate physicians according to a capped fee schedule.

Question 22

Individual practice associations (IPAs)

Answer 22

Partnerships of independent physicians, health professionals, and group practices. Charge lower fees to designated populations of employees than fees charged to others

Question 23

Preferred provider organization (PPO), 3

Answer 23

• A select group of health-care providers agrees to furnish health-care services to a given population at a lower level of reimbursement than is the case for fee-for-service plans.
• Physicians qualify by meeting quality standards, agreeing to follow cost-containment procedures implemented by the PPO, and accepting the PPO’s reimbursement structure.
• Guarantees physicians minimum patient loads, giving employees financial incentives to use the preferred providers and lower reimbursements for services outside preferred networks

Question 24

Exclusive provider organization (EPO), 2

Answer 24

• Variation of PPO, but more restrictive than PPO plans. They offer reimbursement for services provided within the established network.
• Do not require having a primary care physician

Question 25

Point-of-service (POS) plans (3)

Answer 25

• Similar to PPOs, but require the selection of a primary care physician.
• Employees pay a nominal copayment for each visit to a designated network of physicians
• Can choose from health-care providers outside the designated network of physicians, but employees pay more for this choice