Other Health Plans Flashcards
Health maintenance organizations (HMOs) are _______ ______ entities
Managed care
________ provide both the health care service and health care financing, while _________ health care insurance companies provide only the financing
HMOs; traditional
HMOs are made up of:
An array of physicians, hospitals, and other medical providers who offer a full range of health care services
HMOs are considered _____ plans because the consumer (subscriber) pays a subscription fee in advance for health care services they may need in the future
Prepaid
In addition to a co-payment paid by the subscriber, the HMO pays a _______ fee to a health care provider
Capitation
The capitation fee is a:
Fixed monthly fee paid to the healthcare provider based on the number of HMO members, not per HMO subscriber visit or service
Gatekeeper concept
When subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) and they must always see them first (except in emergencies) when seeking medical care from the HMO
HMOs operate within a specified _____ ______
Geographical area
Features of HMOs
-managed care
-prepaid services
-co-pays
-gatekeeper
-limited choice of providers
-limited service area
A major difference between HMOs and the traditional health care system is the emphasis on _________ _____
Preventative care
Routine physicals, well-child care, immunizations, and diagnostic screening are all included in the HMO ______ ______
Subscription fee
HMOs must provide _______ care
Emergency
HMO services
-preventative care
-emergency care in or out of the service area
-hospital services
-office based care and outpatient services
Preferred provider organizations (PPOs) operate on a ____________ rather than a prepaid basis like an HMO
Fee-for-service
Preferred provider organizations (PPOs) contract with:
A network of hospitals, physicians, laboratories, and other medical practitioners to provide medical services for a fee that is somewhat lower than the usual rate for the area
Individuals sign up to receive their medical care through the PPO in order to take advantage of ______ ______
Lower fees
HMOs are typically _______-panel, entities subscribers must seek care only from providers/physicians that belong to the HMO
Closed
PPOs are typically _____-panel, entities and subscribers are not strictly limited to the plans providers. However, the reimbursement percentage on care received from out-of-network providers is usually considerably lower
Open
The relationship between the PPO and its providers is _______
Contractual
A PPO can be organized by a number of different types of organizations, including:
-insurance companies
-Blue Cross/Blue Shield
-a hospital or a group of hospitals
-an HMO
-a large employer or group of employers
-a trade union
A point-of-service plan is a type of HMO that:
Allows subscribers to obtain care from providers who do not belong to the HMO as well as those who do
Point of service plan
-HMO allows subscribers to use providers outside of the HMO
-no gate keeper for out of network services
-subscribers pay more of the cost
-called open-ended HMO
Traditional indemnity health insurance plans are characterized by:
-provision of care on a fee-for-service basis
-billing and submission of claim forms
-deductibles and coinsurance requirements
-complete freedom on choice of provider
-ability to access specialists without a referral
