Unit 17: Other Health Plans

Question 1

Health Maintenance Organizations (HMO)

Answer 1

managed care
prepaid services 
co-pays no deductible or coinsurance
gatekeeper (PCP)
limited choice of providers 
limited service area 
emphasis on preventive care 
goal: detect conditions early before they require more treatment

Question 2

Preferred Provider Organizations (PPO)

Answer 2

fee for service
managed care
pre-negotiate rates
insured pays less in network

Question 3

Point of Service (POS)

Answer 3

HMO allows subscribers to use providers outside of the HMO
NO gatekeeper for out of network services
Subscribers pay more of the cost
called open-ended HMO

Question 4

Indemnity (Traditional) Plans

Answer 4

provisions of care on a free-for-service basis
billing and submission of claim forms
deductibles and coinsurance requirements
complete freedom on choice of provider
ability to access to specialists without a referral

Question 5

Reducing Hospital Costs

Answer 5

inpatient hospitalization is the most costly type of medical care
outpatient benefits-second surgical opinion, preauthorization, limits on lengths of stays

Question 6

Utilization Management

Answer 6

Prospective review
Concurrent review
Retrospective review-takes place while treatment is being provided