Final view - Medical plans

11: Which of the following is true regarding inpatient hospital care for HMO members?

A Inpatient hospital care is not part of HMO services.

B Care can be provided outside of the service area.

C Care can only be provided in the service area.

D Services for treatment of mental disorders are unlimited.

The HMO provides the member with inpatient hospital care, in or out of the service area. The services may be limited for treatment of mental, emotional or nervous disorders, including alcohol or drug rehabilitation or treatment.

Chapter Recap

This chapter explained key concepts and major types if medical plans, including cost containment measures and federal regulations. Let's recap them:

MEDICAL PLANS CONCEPTS
Medical Plan Characteristics	Prepaid plans - payments are made continuously, regardless of services provided Specified coverages - limit services to one illness or group of coverage Comprehensive care - provide coverage for most types of medical expenses Benefit schedule - state exact coverages under a plan and given costs
TYPES OF PROVIDERS AND BENEFITS
Major Medical Insurance(Indemnity Plans)	High maximum limits Blanket coverage Deductibles paid up front Cost shared after meeting deductible
Health Care Services Organization (HMOs)	Preventive care Prepaid basis Limited to service area Basic benefit services - hospital inpatient, physician, outpatient medical, preventive, urgent care, emergency, diagnostic laboratory, out-of-area coverage Optional benefits - long-term care, nursing services, home healthcare, prescription drugs, dental/vision care, mental health care, substance abuse services
Preferred ProviderOrganizations (PPOs)	Physicians are paid on a fee for service basis No PCP referrals Members can use any physician they choose, but are encouraged to use approved physicians who have previously agreed upon fees
Point-of-Service Plans (POS)	Combination of HMO and PPO plans Employees not locked into one plan; allowed to choose depending on the need for medical services Non-member physicians are paid service fee; patient pays higher coinsurance
COST CONTAINMENT IN HEALTH CARE DELIVERY
Cost Saving Services	Preventive care Hospitalization alternatives Second opinions Preadmission testing Catastrophic case management Risk sharing High quality of care
Utilization Management	Prospective review - claim information submitted before treatment Retrospective review - claim information submitted after treatment Concurrent review - insured's hospital stay monitored and planned for release
Managed Care	Financial incentives for using approved providers or procedures Primary focus of preventive care Improved case management through utilization review Controlled length of hospital stay

10: Who chooses a primary care physician in an HMO?

A HMO subscribers do not have a primary care physician

B The insurer

C A referral physician

D The individual member

When an individual becomes a member of the HMO, he or she will choose a primary care physician. Once chosen, the primary care physician will be regularly compensated for being responsible for the care of that member.

11: All of the following are considered to be supplemental benefits under an HMO plan EXCEPT

A Long-term care.

B Mental health care.

C Prescription drugs.

D Preventive services.

HMOs have the option of providing one or more of the following supplemental benefits: long-term care, nursing services, home health care, prescription drugs, dental care, vision care, mental health care, and substance abuse services.

15: What is NOT a benefit of a POS plan?

A It allows guaranteed acceptance of all applicants.

B It allows the employee to use an HMO provided doctor.

C It allows the employee to use a doctor not covered under the HMO.

D With the Point-Of-Service plan the employees do not have to make a decision between the HMO or PPO plans that lock them in.

A different choice can be made every time a need arises for medical services.