LIFE AND HEALTH EXAMS - OTHER HEALTH PLANS

1) skilled nursing facilities 2) intermediate nursing facilities 3) rehab facilities 4) home health care

4 alternatives to hospital care

1) preventive care 2) emergency care (in or out of the service area) 3) hospital services 4) other services (e.g., office based care and outpatient services)

4 categories of care

1) managed care 2) fee for service 3) pre-negotiated rates 4) insured pays less in network of PPO providers

4 features of PPOs

1) outpatient benefits 2) second surgical opinion 3) preauthorization 4) limits on lengths of stay

4 ways to reduce hospital care costs

1) managed care 2) prepaid services 3) co-pays 4) gatekeeper (PCP) 5) limited choice of providers 6) limited service area

6 features of HMOs

D) PPOs operate on a prepaid basis

All of the following are characteristics of a PPO EXCEPT A) PPOs are typically open panel entities B) the relationship between a PPO and its providers is contractual C) PPOs operate on a fee for service basis D) PPOs operate on a prepaid basis

C) indemnity arrangements

All of the following are examples of managed care plans EXCEPT A) point-of-service plans B) preferred provider organizations C) indemnity arrangements D) health maintenance organizations

B) medical services are provided first, and then they are billed and paid for

All of the following are features of HMOs EXCEPT A) HMO subscribers are not free to choose any provider that they wish B) medical services are provided first, and they they're billed and paid for C) HMOs do not have deductibles or coinsurance, but instead co-payments D) medical services are prepaid before treatment

B) HMOs operate on a fee for service plan

All of the following statements about an HMO are correct EXCEPT A) HMOs control over-utilization of their services by subscribers with the gatekeeper concept B) HMOs operate on a fee for service plan C) HMO subscribers are not free to choose any subscriber that they wish D) HMOs are managed care entities

HMOs provide both the heath care service and the health care financing, while traditional health care insurance companies provide only the financing

Difference between HMOs and traditional health care insurance companies?

closed-panel open panel

HMOs are typically _____ entities subscribers must seek care only from providers/physicians that belong to the HMO. PPOs are typically _____ entities and subscribers are not strictly limited to the plans providers.

fee-for-service prepaid basis insurance premium

PPOs operate on a (fee-for-service/prepaid basis), rather than a (fee-for-service/prepaid basis) like an HMO. Subscribers pay an _____ when they enroll in the PPO. It's generally lower than an HMO fee, but PPO plans also have deductibles, coinsurance, and also co-pays.

B) HMOs provide both the heath care service and the health care financing, but traditional health care insurance companies provide only the financing

The main difference between traditional health insurance arrangements and HMOs is that A) traditional health care insurance companies provide both the heath care service and the health care financing, but HMOs provide only the health care service B) HMOs provide both the heath care service and the health care financing, but traditional health care insurance companies provide only the financing C) HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the service D) traditional health insurance companies provide both the health care service and the health care financing, but HMOs provide only the health care financing

because the consumer (subscriber) pays a subscription fee in advance for health care services they may need in the future

Why are HMOs considered prepaid plans?

capitation fee

a fixed monthly fee paid to the healthcare provider based on the number of HMO members, not per HMO subscriber visit or service

managed care

a number of measures to make the delivery of health care more efficient and cost-effective

co-payments

a relatively small, flat dollar amount that subscribers must pay for each doctor visit

point of service plan

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; sometimes called open-ended HMOs

traditional indemnity plans

characterized by 1) provision of care on a fee-for-service basis 2) billing and submission of claim forms 3) deductibles and coinsurance requirements 4) complete freedom on choice of provider 5) ability to access specialists without a referral

gatekeeper concept

concept that states that when subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) and must always see them first (except in emergencies) when seeking medical care from the HMO

preferred provider organizations (PPOs)

contract with a network of hospitals/physicians/labs to provide medical services for a fee that's somewhat lower than the usual rate for that area

retrospective review

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 more cost-effective outcome in the future

prospective review

occurs before an expensive test or treatment recommended by a physician is actually provided, requires a second opinion, or both

utilization management

places oversight on the provision of medical care to make sure it's appropriate and effective

concurrent review

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