Chapter Eight: Managed Care

Which of the following is a managed care plan?

HMO PPO POS plan Managed care plans include: HMOs, PPOs, and POS plans.

POS plans are a mix of:

HMOs and PPOs Point-of-Service (POS) plans are a mix of the PPO and HMO arrangement. Members of a POS plan can choose whether they want to use in-network or out-of-network providers. The member will pay higher costs for using out-of-network providers, except in an emergency situation. Physicians are typically paid by capitation, or a fixed fee per person, no matter how many medical services are performed.

All of the following are true regarding PPOs, EXCEPT:

PPO members typically pay more than non-PPO members. Preferred Provider Organizations, or PPOs, are a group of medical facilities, physicians and practitioners in a designated geographic area that agree to provide medical services at a reduced cost. The cost of care provided by a PPO is usually less than what non-PPO members are charged. Compared to an HMO, members of a PPO have more providers from which to choose. In an emergency situation, the PPO will pay the full cost, regardless of where and from whom the member receives emergency care.

How do managed care plans control medical care costs?

Requiring plan participants to obtain second surgical opinions Precertification Emphasizing preventative care Managed care health plans are focused on reducing the cost of medical care. Costs are contained by requiring plan participants to obtain second surgical opinions or precertification of certain services, so that the plans are not unnecessarily overused. Managed care plans also emphasize preventive care and keeping healthy by including annual physical exams for plan participants. Managed care plans include health maintenance organizations, preferred provider organizations and point-of-service plans.

All of the following are true regarding HMOs, EXCEPT:

Subscribers may see referral specialists without needing to see primary care physicians. Health Maintenance Organizations (HMOs), sometimes referred to as Health Insuring Corporations (HICs), are managed care cost containment health care programs. HMOs provide health insurance coverage and medical services. HMOs are prepaid programs that focus on preventive care. Subscribers must see their primary care physician before seeing referral specialists.