Exam 2: Understanding Managed Care: Insurance Plans

The type of health maintenance organization (HMO) that contracts with more than one community-based multispecialty group to provide wider geographical coverage is a(n): A)group model. B)individual practice association (IPA) model. C)network model. D)staff model.

List three reasons why managed care organizations (MCOs) are criticized.

Examples of individuals who would qualify for COBRA include: A)employees who are laid off from their jobs. B)employees who quit their jobs. C)children of covered employees who are no longer full-time students. D)divorced ex-spouses of covered employees.

What are the differences between an individual and group insurance contract?

The goals of managed care include all of the following EXCEPT: A)medical care that is medically necessary and appropriate based on the patient's condition and diagnosis. B)medical care rendered by the most appropriate provider. C)medical care rendered in the most appropriate setting. D)medical care rendered in the most profitable setting.

An individual or facility providing medical care is called the __________ .

In comparing group and individual insurance, group insurance provides: A)fewer benefits and lower costs. B)fewer benefits and higher costs. C)better benefits and higher costs. D)better benefits and lower costs.

By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to: A)deliver MCO-required preventive care. B)minimize malpractice suits. C)enroll more members in the health plan. D)maintain their income due to lower payments.

If a physician has ordered surgery for a patient, a managed care organization (MCO) case manager may disallow an inpatient stay if the MCO guidelines designate the procedure as best suited for outpatient care.

Primary care physicians (PCPs) are sometimes referred to as gatekeepers because patients with HMO plans must obtain referrals from them to see specialists.

The majority of payments received in a medical facility come from insurance carriers.

Explain the duties of a primary care physician (PCP) in a health maintenance organization (HMO).

Explain the difference between a premium and a deductible.

The duties of a primary care physician (PCP) in a health maintenance organization (HMO) include: A)acting as a gatekeeper to services. B)coordinating patient care. C)referring patients to specialists. D)all of the above.

The first example of a managed care plan is the Kaiser plan for shipyards and steel mill employees in 1942.

A point-of-service (POS) plan allows members to choose a health maintenance organization (HMO) or preferred provider organization (PPO) once a year at open enrollment.

Managed care is a system that controls the __________ and __________ of health services to members.

Physicians in an individual practice association (IPA) health maintenance organization (HMO): A)are typically capitated. B)see both members and nonmembers of the HMO. C)must act as primary care physicians (PCPs). D)contract only with managed care organizations (MCOs).

The type of policy that would provide coverage for custodial care in a nursing home is: A)short-term health insurance. B)long-term care insurance. C)Medicare. D)supplemental insurance.

Incentives for preferred provider organization (PPO) members to use network providers include: A)lower out-of-pocket costs. B)reduced benefits. C)higher out-of-pocket costs. D)ability to obtain care more quickly.