Unit 17 Other Health Plans

Question 1

features of HMOs

Answer 1

managed care
prepaid services
co-pays
gatekeeper (primary care physician)
limited choice of providers
limited service area

Question 2

HMO services

Answer 2

preventive care
emergency care - in or out of the service area
hospital services
office-based care and outpatient services

Question 3

preferred provider organizations (PPO)

Answer 3

managed care
fee for service
pre-negotiated rates
insured pays less in the network of PPO providers

Question 4

closed-panel

Answer 4

closed network
must seek care only from providers in the HMO (except emergencies)

Question 5

open panel

Answer 5

open network
not strictly limited to INN providers. lower reimbursement rate for OON

Question 6

point-of-service (POS) plan

Answer 6

type of HMO sometimes referred to as a gatekeeper PPO or open-ended HMO
HMO allows subscribers to use providers outside of the HMO
no gate keeper for out of network services
subscribers pay more of the cost

Question 7

indemnity (traditional insurance) plans

Answer 7

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

Question 8

cost-saving measures

Answer 8

cost containment - managed care
-reduce hospital care costs
–outpatient benefits, preauths
-encourage preventive care

Question 9

alternatives to hospital care

Answer 9

skilled nursing facilities
intermediate nursing facilities
rehabilitative facilities
home health care