VI. Medical Plans Flashcards
Why do HMOs encourage members to get regular check ups?
What does HMO stand for?
Catch disease at earliest stages
Health Maintenance Organizations
Explain gatekeeper concept
PCP in charge of recommending specialist to keep costs down.
How is POS plan different than traditional HMO?
Point-of-Service plan is a combo of PPO and HMO. Like HMOs, there is a contractual agreement with healthcare providers however plan members do not have to use only in-network providers though the cost may be higher. Getting a referral from a PCP will have better coverage than when self-referring.
On what basis does a managed care plan preferably provide care?
Managed care encourages preventive care
What is another name for prospective review?
Precertification provision- submitting a claim prior to treatment so see coverage and rates.
What is the purpose of a concurrent review?
Make sure everything is proceeding according to schedule and that the insured will be released from the hospital as planned.
Name at least 3 Criteria that would make an individual eligible for HIPAA
18 months of continuous credible health coverage
Covered under a group plan in most recent insurance
Have used up any COBRA or state continuation coverage
Not eligible for Medicare or Medicaid
No other Health Insurance
Apply for Individual insurance within 63 days of losing prior coverage.
What are the eligibilities requirements for coverage through the Health Insurance Marketplace?
U.S Citizen or national or be lawfully present in the United States
Must live in the USA
Cannot be currently incarcerated
What do the metal levels mean in the Marketplace plans?
Bronze: 60%
Silver: 70%
Gold: 80%
Platinum: 90%
How much inpatient care must be provided by Health Ins. companies that provide maternity benefits following a vaginal delivery? Caesarean?
Vaginal: 48
Caesarean: 96
