Unit 27: Health Insurance Providers Flashcards

Question

HMOs are exclusively what? (handwritten note)

Answer 1

traditional health insurance - a reimbursement basis (insured or provider reimbursed for all/part of medical expenses actually incurred

Answer 2

HMOs deal with treatment before while Health insurance doesn't deal with preventitive programs but instead pay only after the fact of diesease or injury

Answer 3

They still provide for hospital, surgical, medical treatment at services are needed.

Answer 4

In traditional health insur, the consumer receives health care from one group of professionals (docs, hospitals, therapists, etc) but financial coverage comes from a separate entity - insur co.

Answer 5

An HMO provides both the health care services AND the health care coverage

Answer 6

HMO made up of group of medical practitioners who have contracted to provide services to HMO members at agreed-upon prices.

Answer 7

Member agrees to pay a specified amount in advance to cover required hospital/medical services.

Answer 8

within a designated service area (often within a certain country or distance from HMO facility)

Answer 9

If the HMO operates in a service area of an employer with 25 or more employees and provides health benefits to those employees, option to enroll in an HMO must be offered as an alternative to traditional health insurance.

Answer 10

dual choice option or dual choice law

Answer 11

employer must contribute equally to either type of health insur coverage

Answer 12

employee choosing HMO pays the difference

Answer 13

For Profit: Usually (not always) HMO is a producers' cooperative operated by a group of physicians Non-profit: If it is a consumer cooperative, docs are salaried employees of HMO

Answer 14

HMO contracts with an independent medical group that specializes in a varity of medical services to provide the services to HMO subscribers

Answer 15

HMO pays the medical group not the individual services providers

Answer 16

A fixed amount paid monthly to the group (medical group entity) for each HMO member Allows HMO to make money on those members not using many services vs. the money they lose on higher use members.

Answer 17

Contracting physicians are paid employees on staff of the HMO, often in a clinic setting at HMO facility. HMO may even own/operate a hospital in some cases

Answer 18

- Operates similar to staff model - a network increases accessibility to providers as a convenience for HMO subscribers who might otherwise have to go to a clinic far from home/work

Answer 19

allows HMO to contract separately with any combo of physicians, medical groups, or physician associations. *** This gives HMO members maximum fredom of choice of physicians/locations ***

Answer 20

1. group (group model) 2. Staff members (work on HMO staff) 3. Create Network (or numerous doctors) for people to go see 4. Sole practitioner can be apart

Answer 21

- another way to characterize HMOs - A panel is a network (handwritten note) - Docs, hospitals, and other health care providers are referred to as the HMO's panel

Answer 22

Any and all providers who want to provide services for the HMO may do so as long as they agree to the HMOs requirements

Answer 23

The HMO choses a limited number of health care providers chosen by HMO. subscribers must receive care from this closed panel of providers

Answer 24

Buddy, there is a list of 7 but none are highlighted

Answer 25

Buddy, there is a list of 8 but only "prescription drugs" is highlighted

Answer 26

purchase additional services (supplemental services) from the HMO only as an "adjunct" to the basic care offered. Adjunct = add on

Answer 27

a set fee you pay for a doctor visit or prescription. You typically pay it at your appointment or when you pick up a prescription.

Answer 28

Members are charged only nominal amounts (co-pays) for basic services on top of the original monthly payment

Answer 29

- members must select a primary care physician (PCP) who manages/authorizes/refers to specialists, etc. - PCP must be involved in all aspects of a member's health care in order for claims to be paid. Think of this person is opening (or refusing to open) the gate between the member and the healthcare providers. (FYI: to me, a babysitter – my new medicare blue cross has to run everything by Dr. Licht (yuck). I could have paid more money per month to avoid this inconvenience)

Answer 30

HMOs are permitted to require co-payments on these services, as well as charging an additional monthly payment for these additional services.

Answer 31

members have 24 hr acess to the HMO (health care professionals must be available to respond during non-business hrs.)

Answer 32

- In an employer-sponsored group plans, it's a period each year when employees choose to enroll or remain enrolled in HMO or make changes to their health plans. - A period each year when an HMO must advertise availability to the general public on an individual basis (for them to join)

Answer 33

In HMO coverage offered to a GROUP, it may not refuse to cover an individual member because of a preexisting condition

Answer 34

They are any complaints in regard to coverage. Weatherby coverage offered, pain under denial, health claims, and similar items. The complaints are reviewed internally might eventually be referred to the state insurance department

Answer 35

These are Compliance regarding the quality of care received by an HMO provider. Medical personnel reviewed these type of complaints HMO subscribers must receive a document, indicating how complaints can be registered

Answer 36

Have mechanisms in place to handle 1. coverage complaints 2. care complaints

Answer 37

HMOs are prohibited from canceling or disenrolling members because of their current health status or usage of health services

Answer 38

- PPOs are an effort to reduce medical costs - an arrangement where a group of providers, independent hospitals in a certain area (a state, etc.) agree to provide a range of services at PREARRANGED costs.

Answer 39

Typically the agreed upon fee is lower for the HMO members

Answer 40

fee for service basis

Answer 41

they receive a guaranteed payment from the PPO and a potential increase in number of patients

Answer 42

managed health care systems

Answer 43

1. Health maintenance organizations 2. Preferred Provider organizations

Answer 44

1. Stock companies have stock holders and mutual companies have policyholders 2. Stock companies sell stocks to stockholders who buy stocks from the stock company..... they get paid in dividends 3. mutual companies are owned by policyholders and ... the policyholders get paid by receiving excess earnings returned

Answer 45

stock or mutual company