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CRCR Guide questions and answers graded A+ 2024/2025
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CRCR Guide questions and answers graded A+ 2024/2025
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CRCRGuide
Health
Maintenance
Organization
(HMO):
-
ANSEnsures
comprehensive
health
maintenance
and
treatment
services
for
an
enrolled
group
of
persons
based
on
a
monthly
fee.
The
plan
will
provide
the
beneficiary
with
a
list
of
physicians
from
which
they
may
choose
as
their
Primary
Care
Physician
(PCP).
The
beneficiary
must
contact
their
PCP
to
coordinate
their
care.
The
PCP
will
provide
the
beneficiary
with
a
referral
to
a
specialist
or
obtain
pre-cert
for
non-emergent
care.
This
type
of
insurance
only
covers
approved
services
provided
by
HMO
providers.
If
the
patient
goes
outside
the
HMO,
the
patient
is
liable
for
the
total
charges.
Preferred
Provider
Organization
(PPO)
-
ANSThis
plan
is
the
closest
to
an
indemnity
plan.
The
employer
and
the
health
insurance
carrier
contract
to
purchase
health
care
services
from
a
selected
group
of
participating
providers.
These
providers
agree
to
follow
the
utilization
management
and
other
procedures
that
are
implemented
by
the
PPO
and
agree
to
accept
the
PPO
reimbursement
structure
and
payment
levels.
With
this
type
of
plan,
the
beneficiary
may
choose
to
use
a
non-PPO
provider
but
will
have
higher
coinsurances
and/or
deductibles.
Silent
PPO's
-
ANSA
scheme
where
insurers
that
don't
offer
PPO
policies
apply
the
contracted
PPO
discounted
rate
to
the
patient's
bills
that
are
not
part
of
the
PPO
network.
These
payers
obtain
the
database
of
the
preferred
provider
rates,
usually
from
a
broker.
These
appear
as
legitimate
discounts
on
the
remittance
advice
(R/A).
See
page
3
of
this
section
for
additional
information.
Point
of
Service
(POS)
-
ANSAn
HMO
that
offers
indemnity
type
options.
The
Primary
Care
Physician
(PCP)
usually
make
referrals
to
other
providers
within
the
plan.
But
with
the
POS
plan,
the
beneficiary
may
self-refer
themselves
outside
the
plan
and
still
have
some
coverage.
If
the
PCP
refers
outside
the
network,
the
plan
pays
all
or
most
of
the
bill.
If
the
beneficiary
wants
to
use
a
provider
outside
the
network
and
the
service
is
a
covered
one,
the
beneficiary
will
have
higher
out
of
liability
Exclusive
Provider
Organization
(EPO)
-
ANSThis
type
of
plan
is
similar
to
the
PPO
but
unlike
PPO's,
they
limit
their
beneficiaries
to
participating
providers.
Beneficiaries
are
required
to
receive
all
their
care
from
providers
participating
in
the
EPO
Medicare
Advantage
-
ANSHealth
plan
options
that
are
part
of
the
Medicare
program.
A
patient
must
have
both
Part
A
and
Part
B
benefits
to
be
eligible
for
a
Medicare
Advantage
plan.
The
patient
continues
to
pay
their
monthly
Part
B
premium
to
Medicare
and
most
likely
a
premium
to
the
Medicare
Advantage
plan
for
the
extra
benefits
offered.
Some
of
the
most
common
plans
are:
Medicare
Health
Maintenance
Organization
(HMO),
Medicare
Special
Needs
Plans,
Private
Fee
for
Service
(PFFS)
plans,
and
Preferred
Provider
Organizations
(PPO).
Other
less
common
are:
Medical
Savings
Account
(MSA),
this
type
combines
a
high
deductible
with
a
bank
account
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