Exam 2: Understanding Managed Care: Insurance Plans

Explain how members see a specialist in a health maintenance organization (HMO) plan.

A primary care physician (PCP) in a health maintenance organization (HMO) can be an OB/GYN.

The type of insurance coverage that provides protection against a specific type of accident or illness is: A)outpatient. B)major medical. C)special risk. D)catastrophic health insurance.

Why is knowledge of the history of healthcare in America important for a medical office assistant?

Group insurance is issued to an employer to provide coverage for: A)employees only. B)employees and spouses only. C)employees and children only. D)employees and all their dependents.

The major types of managed care plans are: A)health maintenance organization (HMO) and preferred provider organization (PPO). B)preferred provider organization (PPO), point-of-service (POS), and indemnity. C)health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service (POS). D)health maintenance organization (HMO) and point-of-service (POS).

In 2011, the new health care reform law required insurers to offer dependent coverage for adult children up to age ___ to be included on parents' coverage. A)26 B)21 C)18 D)24

Advantages of managed care include all of the following EXCEPT: A)hospitals and physicians provide services more efficiently. B)providers strive to improve the quality of their care. C)physicians run the risk of adverse selection by enrollees. D)data is collected and analyzed to measure health outcomes.

The type of insurance that provides coverage for a designated period of time is: A)medical insurance. B)special risk. C)short-term health insurance. D)long-term care.

In a managed care organization (MCO) contract, the provider will bill the patient the difference between the standard fee and the contractual or discount amount.

Utilization guidelines are used to: A)determine if services are medically necessary. B)provide physician offices with more paperwork. C)determine if the provider is in the network. D)determine if an employee is covered under the plan.

All of the following are types of health maintenance organizations (HMOs) EXCEPT the: A)group model. B)preferred provider model. C)individual practice association. D)open access model.

Health maintenance organization (HMO) plans add a point-of-service (POS) option to: A)lower the cost of the plan. B)lower the benefits of the plan. C)provide physicians with more choice. D)provide members with more choice.

Which of the following is true of managed care contracts with providers?

To determine the amount due from a patient, it is necessary to know the: A)billed amount. B)allowed amount. C)adjusted amount. D)diagnostic code.

Preferred provider organization (PPO) members typically do not have to obtain a referral to see a specialist.

When a provider agrees to receive payment directly from the patient's insurance carrier, it is accepting __________ .

The type of health maintenance organization (HMO) plan that employs salaried physicians who treat members in facilities owned and operated by the HMO is a(n): A)group model. B)individual practice association (IPA) model. C)network model. D)staff model.

The type of insurance coverage that pays a per diem for each day a patient is in the hospital is: A)hospital. B)hospital indemnity. C)medical. D)major medical.

A point-of-service (POS) plan allows members to: A)choose a health maintenance organization (HMO) or preferred provider organization (PPO) option each time they seek care. B)receive medical care from any in-network or non-network provider. C)do both a and b. D)do neither a nor b.