Unit 17 - Other Health Plans

Question 1

Prepayment for Health Care Services - HMOs

Answer 1

HMOs are considered prepaid plans because the consumer (subscriber) pays a subscription fee in advance for health care services they may need in the future.

• room and board
• maternity care
• general nursing care
• use of operating room and facilities
• use of intensive care unit
• x-rays, labratory, and other diagnostic tests
• drugs, medications, and anesthesia
• physical, radiation, and inhalation therapy

Question 2

Capitation Fee

Answer 2

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

Question 3

Co-Payments / Co-Pays

Answer 3

HMOs introduced the concept of co-pays instead of deductibles or coinsurance. A co-pay is a relatively small, flat dollar amount that subscribers must pay for each doctor visit.

Question 4

Gatekeeper Concept / Primary Care Physician

Answer 4

This is a way the HMOs control overutilization of their services by subscribers. When subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) and they must always see them first (except for emergencies) when seeking medical care.
Cannot see specialists without a referral from a primary care physician.

Question 5

Limited Choice of Provider

Answer 5

HMO subscribers must choose a provider/physician under contract with the HMO.
If they are no under contract with the HMO, they must choose a doctor from the HMO. The doctor may be able to join,

Question 6

Limited Service Area

Answer 6

HMOs operate within a specific geographic area or designated service area such as a certain county or within the surrounding area.

Question 7

Emergency Care

Answer 7

HMOs must provide emergency care, including ambulance service.
HMOs must reimburse subscribers for emergency care obtained outside of the HMOs designated service area.

Question 8

Hospital Services

Answer 8

Services include:

• room and board
• maternity care
• general nursing care
• use of operating room and facilities
• use of ICU
• x-rays, laboratory, and other diagnostic tests
• drugs, medications, and anesthesia
• physical, radiation and inhalation therapy

Question 9

Other services

Answer 9

HMOs may include certain supplemental health care services or provide them for an additional fee:

• prescription drugs
• vision care
• dental care
• home health care
• nursing services
• long-term care
• substance abuse treatment

Question 10

Preferred Provider Organizations (PPOs)

Answer 10

PPOs contract with a network of hospitals, physicians, labroatories, and other medical practioners to provide medical services for a fee that is somehwat lower than the usual rate for that area.

They operate on a fee-for-service rather than a prepaid basis like an HMO.

Question 11

Open Panel vs Closed Panel

Answer 11

HMOs are typically closed panel, or closed network, entities subscribers must seek care only from providers/physicians that belong to the HMO (except out of network emergencies)

PPOs are typically open panel, or open network, entities and subscibers are not strickly limited to the plas providers.

Question 12

Point-of-Service Plans (Gatekeeper PPOs)

Answer 12

This plan is 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.

If subscribers choose to access care outside of the HMO, the plan operates like a PPO or traditional insurance plan.

• There is no primary care physician that acts as a gatekeeper
• Providers bill the individual a fee for the services rendered, and the individual must submit a claim form to the HMO for reimbursement.
• Subscribers are not reimbursed for 100% of their expenses but rather for only a percentage such as 60% or 80%, like a coinsurance requirement.

Called open-ended HMO

Question 13

Indemnity (Traditional Insurance) Plans

Answer 13

Traditional Indemnity Plans are still offered by commercial insurers.

They are characterized by the following:

• provision of care on a fee-for-service basis
• billing and submission of claim forms
• deductibles and coinsurance requirement
• complete freedom on choice of provider
• ability to access to specialists without a referral

Question 14

Health Care Cost Containment (Managed Care)

Answer 14

• Preventative Care
• Reducing Hospital Care Costs
• Utilization Management

Question 15

Preventative Care includes:

Answer 15

• Wells checks
• Annual visits
• Routine visits
• Wellsness programs
• Smoking cessation programs
• Weight loss programs

Question 16

Reducing Hospital Care Costs - Outpatient Benefits

Answer 16

Many procedures can be performed safely and effectively without the patient staying in the hospital overnight.

Question 17

Reducing Hospital Care Costs - Second Surgical Opinion

Answer 17

Doctors do not always agree on whether sugery is needed. This allows or requires a consulation with a doctor other than attending physician to see if an alternative method of treatment would be desirable.

Question 18

Reducing Hospital Care Costs - Preauthorization

Answer 18

If treatment requiring hospitalization is recommended, precertification is required prior to obtaining the treatment.

Question 19

Reducing Hospital Care Costs - Limits on Lengths of Stay

Answer 19

In consultation with medical experts, insurers determined the appropriate number of days for vaious types of treatment, assuming no complications.

Question 20

Reducing Hospital Care Costs - Skilled Nursing facilities

Answer 20

provide round the clock care for aptients who need inpatient supervision by a registered nurse, but who do not require the acute level of care provided by a hospital.

Question 21

Reducing Hospital Care Costs - Intermedicate nursing facilities

Answer 21

Provide intermittent nursing care for patients who do not need 24-hour supervision.

Question 22

Reducing Hospital Care Costs - Rehabilitative facilities

Answer 22

provide limited amount of medical care along with the personal care necessary for patients to recover from major surgeries or serious injuries or illness.

Question 23

Reducing Hospital Care Costs - Home Health Care

Answer 23

is provided by agencies the employ a state of nurses that make visits to patient’s home on a regular basis. This is used when patients need some sort of ongoing medical care but do not need supervision.

Question 24

Utilization Mangement

Answer 24

Places oversight on the provision of medical care to make sure it is appropriate and effective.

1. Prospective review
2. Concurrent review
3. Retrospective review

Question 25

Prospective review

Answer 25

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

Information on the case is reviewed to determine necessity and cost-effectiveness.

“Precertification” or “Preauthorization”

Question 26

Concurrent Review

Answer 26

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.

Question 27

Retrospective Review

Answer 27

Is 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 most cost effective outcome in the future.