Unit 17 Other Health Plans Flashcards
The Health Maintenance Organization Act of ____ introduced alternatives to the existing fee-for-service method of payment for health services. In the following decades, other forms emerged such as (PPOs) and (POS) plans.
1973
____(HOMs) are managed care entities. They departed from the traditional health care delivery and payment system. HMOs provide both the health care service and the health care financing, while traditional health care insurance companies provide only the financing.
Health Maintenance Organizations
HMOs are considered prepaid plans because the consumer (subscriber) pays a subscription fee in advance for health care services they may need in the future. In addition to a co-payment paid by the subscriber, the HMO pays a ____ fee to a health care provider. This 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.
Capitation Fee
HMOs introduced the concept of ____, or co-pays instead of deductibles or coinsurance. A co-pay is a relatively small, flat dollar amount that subscribers pay for each doctor visit.
Co-payments
Another way HMOs control overutilization of their services by subscribers is with the ____ concept. When subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) and the must always see them first (except in emergencies) when seeking medical care from the HMO. Subscribers cannot see specialists without a ____ from a PCP.
Gatekeeper Concept
Referral
Do HMO subscribers have to choose a provider/physician under contract with the HMO?
Yes, unless the doctor can join the HMO
HMOs operate within a specific geographic are or ____ service area such as a certain county or within the surrounding area. Individuals must live within this service area to subscribe to the HMO.
Designated Service Area
A major difference between HMOs and the traditional health care system is the emphasis on ____ care. Routine physicals, well-child care, immunizations, and diagnostic screening are all included in the HMO subscription fee.
Preventive Care
HMOs must provide emergency care, including ambulance service, available 24 hours a day, 365 days a year, within its ____ area. In addition, HMOs must ____ subscribers for emergency care obtained outside of the HMO’s designated service area from non-HMO providers.
Designated Service Area
Reimburse
HMO hospital services must include: (8)
- Room and board
- Maternity care
- General nursing care
- Use of operating room and facilities
- Use of intensive care unit
- X-rays, lab, and other diagnostic tests
- Drugs, medications, and anesthesia
- Physical, radiation, and inhalation therapy
HMOs may include certain supplemental health care services or provide them for an additional fee, such as: (7)
- Prescription drugs
- Vision care
- Dental care
- Home health care
- Nursing services
- Long-term care
- Substance abuse treatment
PPOs contract with a network of hospitals, physicians, labs, and other medical practitioners to provide medical services for a fee that is somewhat lower than the usual rate for that area. Individuals sign up to receive their medical care through the PPO in order to take advantage of those lower fees. The providers agree to accept a lower fee in order to have access to the PPO’s subscribers.
PPOs operate on a ____ rather than a prepaid basis like an HMO. PPO subscribers pay an insurance premium when they enroll in the PPO. The premium is generally less than an HMO fee, but PPO plans also have deductibles, coinsurance, and also co-pays. Out-of-pocket costs depend on the amount of care provided.
Fee-for-Service
HMOs are typically ____, or closed network, entities subscribers must seek care only from providers/physicians that belong to the HMO (except in emergencies).
Closed Panel
PPOs are typically ____, or open network, entities and subscribers are not strictly limited to the plan’s providers. the reimbursement percentage on care received from out-of-network providers however is usually considerably lower (50-60% VS 80-90%)
Open Panel
A PPO is a risk-bearing entity separate from the providers of health care services. The relationship between the PPO and its providers is contractual.
However, a PPO can be organized by a number of different types of organizations, including: (7)
- Insurance companies
- Blue Cross/Blue Shield
- A hospital or group of hospitals
- A group of physicians
- An HMO
- A large employer or group of employers
- A trade union
A ____ 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. If subscribers choose to access care within the HMO, they choose a PCP who acts as a gatekeeper to the HMO’s network of providers. For this reason, these plans are often referred to as ____.
Point of Service Plan
Gatekeeper PPOs
Point-of-Service Plans: If subscribers choose to access care outside of the HMO, the plan operates like a PPO or traditional insurance plan. Subscribers are not reimbursed 100%, it’ll be something like 60-80%.
Because subscribers are not limited to selecting only providers which belong to the HMO, POS plans are sometimes called ____ HMOs.
Open-Ended HMOs
Traditional indemnity plans are still offered by commercial insurers. They are characterized by the following:
1. Provision of care on a ____ basis
2. Billing and submission of ____ forms
3. Deductibles and ____ requirements
4. Complete freedom on choice of ____
5. Ability to access specialists without a ____.
- Fee-for-Service
- Claims
- Coinsurance
- Providers
- Referral
Traditionally, controlling health care costs was not thought to be an area of responsibility for insurers. But as health care costs began to rise dramatically, insurers responded by implementing a number of measures to make the delivery of health care more efficient and cost-effective. These measures came to be known as ____.
PREVENTIVE CARE IS PART OF THIS
Managed Care (Health Care Cost Containment)
Reducing Hospital Care Costs:
____ - Many procedures can be performed safely and effectively without the patient staying overnight in the hospital. Insurers began encouraging the use of a hospital’s outpatient facilities by providing relatively higher levels of reimbursement for treatment received on an outpatient rather than an in-patient basis.
Outpatient Benefits
Reducing Hospital Care Costs:
____ - Doctors do not always agree on whether surgery is needed to treat a particular condition. Second surgical opinions allow or require consultation with a doctor other than their attending physician to see if an alternative method of treatment would be desirable.
Second Surgical Opinion
Reducing Hospital Care Costs:
____ - If treatment requiring hospitalization is recommended, PRECERTIFICATION is required prior to obtaining treatment.
Preauthorization
Reducing Hospital Care Costs:
____ - In consultation with medical experts, insurers determined the appropriate number of days for various types of treatment. They limited payment to a certain number of days for a given procedure, assuming no complications.
Limits on Lengths of Stay
Alternatives to Hospital Care:
____ - provide round-the-clock care for patients who need inpatient supervision by a registered nurse, but who do not require the acute level of care provided by a hospital.
Skilled Nursing Facilities
