Exam 2: Understanding Managed Care: Insurance Plans

The fixed dollar amount a member pays at each office visit or hospital encounter is the: A)copayment. B)coinsurance. C)deductible. D)premium.

The percentage of the provider's fees that the patient has to pay is known as: A)copayment. B)coinsurance. C)deductible. D)stoploss.

Traditional insurance plans tend to cover more preventive services than health maintenance organizations (HMOs).

Physician-hospital organizations (PHOs) may include: A)nursing homes. B)laboratories. C)surgery centers. D)all of the above.

List some of the advantages of managed care.

What are some of the ways that managed care organizations (MCOs) create an increased administrative burden on a physician's office?

Written approval from a managed care plan or insurer before a patient is admitted to a hospital or receives a particular treatment is known as __________ .

Managed care systems ensure the delivery of high-quality care while managing costs through: A)provider networks and discounted fees for services. B)provider networks and regular premium increases. C)prohibiting the use of out-of-network providers. D)discounted fees for services and mandatory high deductibles across all health plans.

An insurance identification card usually includes all of the following information EXCEPT: A)name of the insurance policy or health plan. B)name of the subscriber. C)detailed benefit information. D)insurance policy number.

A characteristic of a staff model health maintenance organization (HMO) is that it: A)contracts with a multispecialty physician group. B)is a decentralized healthcare delivery system. C)employs salaried physicians. D)agrees to contractual discounts with physicians.

In a managed care organization (MCO), a primary care physician (PCP) is typically any of the following EXCEPT: A)general practitioner. B)family practitioner. C)dermatologist. D)internist.

An exclusive provider organization (EPO) is similar to a preferred provider organization (PPO) because they both have: A)a limited provider network. B)gatekeepers. C)payment by capitation. D)flexible benefit design.

The purpose of a withhold program is to: A)encourage providers to use cost-effective methods. B)reward physicians for ordering extensive tests. C)discourage preventive care. D)promote the use of specialty physicians.

The type of managed care plan in which members can only obtain care from providers within the network is the: A)health maintenance organization (HMO). B)preferred provider organization (PPO). C)point-of-service (POS). D)indemnity.

As government program healthcare costs increased, federal and state governments: A)increased premiums. B)increased taxes. C)increased deductibles. D)decreased benefits.

If a member in a health maintenance organization (HMO) sees a specialist without a referral from his or her PCP, the HMO will not pay for the service.

Providers who contract with managed care organizations (MCOs) must provide care according to the MCO's policies and guidelines in order to: A)increase revenue. B)increase patient load. C)be listed in the provider directory. D)be paid for services provided.

Primary care physicians (PCPs) in a health maintenance organization (HMO) can include: A)family practice, general practice, internal medicine, and OB/GYN. B)family practice and general practice only. C)family practice, general practice, and internal medicine only. D)family practice, general practice, and OB/GYN only.

Terms used to refer to fees in an insurance contract include all of the following EXCEPT: A)customary. B)ordinary. C)reasonable. D)usual.

Which of the following plan types does not use a network of providers? A)Indemnity plan B)PPO plan C)HMO plan D)EPO plan