Plan Types Flashcards
How do HMOs operate in Florida health insurance, and how do they encourage preventive medicine?
HMOs operate through a group enrollment system, where each member pays a premium. Services are prepaid, encouraging individuals to see a doctor early for preventive measures.
What types of arrangements do most HMOs have with hospitals and clinics?
Most HMOs operate their own hospitals and clinics, staffed by health care professionals employed by the HMO.
What are the two operational bases for HMOs in Florida, and what is the difference between closed-panel and open-panel?
HMOs in Florida operate on either closed-panel or open-panel basis. In a closed-panel system, patients are limited to a specific network of healthcare providers, while in an open-panel system, patients have the flexibility to seek care from both in-network and out-of-network providers
What are the requirements for providers to start an HMO in Florida?
To start an HMO in Florida, providers must obtain a certificate of authority from the Department, a valid Health Care Provider Certificate from the Department of Health and Rehabilitative Services, meet capital and surplus minimum requirements, file rates, contracts, and forms as required by the Legislature, make a $10,000 deposit to the Rehabilitation Administration Expense Fund, and become a member of the Florida Health Maintenance Organization Consumer Assistance Plan.
Who can sell HMO contracts in Florida?
Only licensed agents or full-time salaried employees/officers of an HMO who do not primarily solicit HMO contracts from the public and receive no commissions for such contracts.
What are some unfair trade practices with regard to HMOs?
Unfair practices include misrepresentation, false advertising, defamation, unfair claim settlement practices, and operating without a subsisting certificate of authority. Fines for violations can be up to $200,000.
What is an Exclusive Provider Organization (EPO) and how does it function?
An Exclusive Provider Organization (EPO) is a type of preferred provider organization in which individual members use specific preferred providers instead of a variety. EPOs are characterized by primary physicians who monitor care and make referrals to a network of providers.
What are Prepaid Service Organizations, and how do they differ from fee-for-service plans?
Prepaid plans provide medical and hospital benefits in the form of service rather than dollars. In prepaid plans, providers are compensated regularly whether or not they provide service, but no additional compensation is provided when services are rendered. Fee-for-service plans receive payment for each service provided.
What are indemnity plans, and how do they function?
Indemnity plans pay health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred. They are often offered as deductible health care plans, and most plans have co-payment requirements.
Expense-based Plans
These plans reimburse health policy benefits based on actual expenses incurred.
Discount Medical Plan Organization (DMPO):
Definition: Entity providing discount medical plans.
Licensing: Regulated by the Office of Insurance Regulation (OIR).
Disclosures: Must provide in writing that it’s NOT insurance, offers discounts, doesn’t pay providers directly, and members are responsible for all services.
Prohibited Activities of Discount Plan Organizations:
Using the term “insurance” for marketing.
Misleading terms like “health plan,” “coverage,” etc.
Restricting access to plan providers.
Paying providers for medical services.
