Other Health Plans Chapter 17 Flashcards
Which of the following statements about a health maintenance organization (HMO) is correct?
A. it does not need to be approved by the state before offering services to its subscribers
B. it provides or arranges for health care services for the benefit of its subscribers
C. it provides health insurance coverage specifically to people who cannot obtain coverage from insurance companies
D. it generally hires medical professionals as employees to provide health care services to the general public
B
A formal technique designed to evaluate the clinical necessity, appropriateness, or efficiency of health care services, procedures, or settings is known as
A. utilization review
B. adverse selection
C. external review
D. retrospective review
A
Health maintenance organizations are known for stressing the provision of
A. health care and services to government employees
B. health care and services on a fee for service basis
C. preventive care
D. health care and services in hospital settings
C
All of the following are features of HMOs except
A. prepaid services
B. gatekeepers
C. extensive choice of providers
D. co-pays
C
Which of the following statements concerning HMOs is correct?
A. HMOs are generally owned by life insurance companies
B. HMOs place special emphasis on preventive health care
C. HMOs primarily provide emergency medical treatment for their members
D. participants pay a onetime, fixed fee in advance for health care services
B
All of the following home health care services will be covered by group plans except
A. emergency surgery
B. physical therapy
C. occupational therapy
D. nutritional consultation
A
All of the following are types of utilization management except
A. concurrent review
B. retrospective review
C. preauthorization review
D. prospective review
C
A point of service (POS) plan is most like a health maintenance organization (HMO) in which of the following ways?
A. both allow subscribers to use outside providers
B. both are generally nonprofit organizations
C. both use a primary care physician
D. both feature providers who are employees of the plan itself
C
Which of the following statements regarding PPOs is true?
A. PPOs do not afford access to a primary care physician
B. helth care services offered by out out network providers have lower deductibles and coinsurance than those offered by in network providers
C. PPOs do not use managed care procedures
D. health care services offered by in network providers are contracted between the PPO and the providers
D
According to federal law, HMO basic health care services include all of the following except
A. vision care services
B. emergency services
C. physician services
D. inpatient and outpatient hospital services
A
All of the following are alternatives to hospital care except
A. intermediate nursing
B. home health care
C. assisted living care
D. skilled nursing
C
HMOs can be a key factor in reducing
A. the number of physicians needed
B. the number of hospitals
C. nurses unemployment
D. health care costs
D
The fixed monthly fee paid to the healthcare provider is called
A. coinsurance
B. the fee for service
C. the deductible
D. the capitation fee
D
Which of the following statements about preferred provider organizations is not correct?
A. physicians who are part of a PPO are in private practice
B. they operate on a fee for service basis
C. they offer health care services to their members at discounted rates that are negotiated in advance
D. they offer health care coverage to low income individuals
D
HMOs include all of the following features except
A. a fee for service policy
B. a gatekeeper (primary care physician)
C. prepaid services
D. managed care
A
