Unit 17 Other Health Plans

Question 1

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.

Answer 1

1973

Question 2

____(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.

Answer 2

Health Maintenance Organizations

Question 3

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.

Answer 3

Capitation Fee

Question 4

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.

Answer 4

Co-payments

Question 5

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.

Answer 5

Gatekeeper Concept

Referral

Question 6

Do HMO subscribers have to choose a provider/physician under contract with the HMO?

Answer 6

Yes, unless the doctor can join the HMO

Question 7

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.

Answer 7

Designated Service Area

Question 8

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.

Answer 8

Preventive Care

Question 9

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.

Answer 9

Designated Service Area

Reimburse

Question 10

HMO hospital services must include: (8)

Answer 10

1. Room and board
2. Maternity care
3. General nursing care
4. Use of operating room and facilities
5. Use of intensive care unit
6. X-rays, lab, and other diagnostic tests
7. Drugs, medications, and anesthesia
8. Physical, radiation, and inhalation therapy

Question 11

HMOs may include certain supplemental health care services or provide them for an additional fee, such as: (7)

Answer 11

1. Prescription drugs
2. Vision care
3. Dental care
4. Home health care
5. Nursing services
6. Long-term care
7. Substance abuse treatment

Question 12

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.

Answer 12

Fee-for-Service

Question 13

HMOs are typically ____, or closed network, entities subscribers must seek care only from providers/physicians that belong to the HMO (except in emergencies).

Answer 13

Closed Panel

Question 14

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%)

Answer 14

Open Panel

Question 15

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)

Answer 15

1. Insurance companies
2. Blue Cross/Blue Shield
3. A hospital or group of hospitals
4. A group of physicians
5. An HMO
6. A large employer or group of employers
7. A trade union

Question 16

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 ____.

Answer 16

Point of Service Plan

Gatekeeper PPOs

Question 17

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.

Answer 17

Open-Ended HMOs

Question 18

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 ____.

Answer 18

1. Fee-for-Service
2. Claims
3. Coinsurance
4. Providers
5. Referral

Question 19

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

Answer 19

Managed Care (Health Care Cost Containment)

Question 20

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.

Answer 20

Outpatient Benefits

Question 21

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.

Answer 21

Second Surgical Opinion

Question 22

Reducing Hospital Care Costs:

____ - If treatment requiring hospitalization is recommended, PRECERTIFICATION is required prior to obtaining treatment.

Answer 22

Preauthorization

Question 23

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.

Answer 23

Limits on Lengths of Stay

Question 24

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.

Answer 24

Skilled Nursing Facilities

Question 25

Alternatives to Hospital Care:

____ - provide intermittent nursing care for patients who do not need 24-hour supervision.

Answer 25

Intermediate Nursing Facilities

Question 26

Alternatives to Hospital Care:

____ - provide a limited amount of medical care along with the personal care necessary for patients to recover from major surgeries or serious injuries or illnesses.

Answer 26

Rehab Facilities

Question 27

Alternatives to Hospital Care:

____ - is provided by agencies that employ a staff of nurses that make visits to a patient’s home on a regular basis. It is used when patients need some sort of ongoing medical care but do not need supervision.

Answer 27

Home Health Care

Question 28

____ places oversight on the provision of medical care to make sure it is appropriate and effective. This oversight can occur at any or all of the following points in the process.
1. Prospective Review
2. Concurrent Review
3. Retrospective REview

Answer 28

Utilization Management

Question 29

____ occurs before an expensive test or treatment recommended by a physician is actually provided, requires a second opinion, or both. Info on the case is reviewed to determine necessity and cost-effectiveness. This review process is referred to as ____ or ____.

Answer 29

Prospective Review

Precertification or Preauthorization

Question 30

____ takes place while treatment is being provided. The insured’s hospital stay is monitored to assure that everything is proceeding according to schedule and that the insured will be released from the hospital as planned.

Answer 30

Concurrent Review

Question 31

____ is done after treatment is complete. The outcome is evaluated to see if treatment was effective and if anything could be changed to produce a better or most cost-effective outcome in the future.

Answer 31

Retrospective Review