HSA 312 - HEALTH INSURANCE AND MANAGED CARE1&2 WITH 100% CORRECT ANSWERS/HSA 312 - HEALTH INSURANCE AND MANAGED CARE1&2 WITH 100% CORRECT ANSWERS/HSA 312 - HEALTH INSURANCE AND MANAGED CARE1&2 WITH 100% CORRECT ANSWERS
HSA 312 - HEALTH INSURANCE AND MANAGED CARE1&2 WITH
100% CORRECT ANSWERS
HSA 312 TEST 1 REVIEW (CHAPTERS: 1, 2, 3) WITH 100% CORRECT ANSWERS
What was considered the forerunner of what we now call health maintenance organizations? -
answer Prepaid groups practices
The original impetus of HMOs development came from what developments in healthcare? -
answer - Employers seeking to control costs
- Providers seeking patient revenues
- Consumers seeking access to health care
How did Blue Cross begin? - answer Started when the Baylor Hospital in Texas offered 1,500
teachers prepaid impatient care.
What are the integral components of managed care? - answer Wellness and Prevention
Primary care orientation
Utilization management
Managed care is best described as: - answer A constantly changing array of health plans,
employers, unions and other purchasers that attempt to manage cost, quality, and access to
care.
Define and explain the impact of The Balance Budget Act (BBA) of 1997 - answer - Permitted
provider organizations to contract directly with medicare as a provider-sponsored organization,
if they met certain requirements.
- Impacts: PSOs lost millions of $$$ and federal waiver program for PSOs expired
Briefly explain how the HMO Act of 1973 contributed to the growth of managed care. - answer -
Authorized start up funding
pg. 1
, 2
- Ensured access to employer based insurance
- Federal qualifications was looked as an approval
The Managed care backlash" resulted in what? - answer - Reduction in HMO memberships
- New Federal and State laws/regulations
- Many states pass "Patient Protection" legislation
- Many lawsuits
- Some HMOs started to have an open access model
- Growth of PPOs
- Improved quality care
Compare PPOs and HMOs. How do PPOs differ from HMOs? - answer PPOs:
- more $$$: most expensive but most freedom
- PPO members can see any doctor who is with PPO without getting a referral from primary
doctor
- have some preventive services offered
HMOs:
- Primary provider is a gatekeeper to see other doctors
- Can only see providers in the same network
- Comes with a set of benefits and preventive services
Name 3 types of defined health benefits plans. Name a defined contribution plan - answer 1.
Individual health insurance plan
2. Self-funded employer plan
3. Medicare & Medicaid
- health savings account is a contribution plan
pg. 2
, 3
Mandated benefits coverage applies to what types of health benefits plans? - answer HMOs
ONLY!!!
What types of laws and regulations are reinsurance and health insurance are subject to? -
answer Subject to stricter rules & regulations under the ADA
Are HMOs licensed as health insurance companies? If not what are they licensed through? -
answer No, licensed through certificate of authority
Name 4 Key common characteristics of PPOs: - answer ○ Smaller panel of providers selected
○ More terms and conditions for participation by providers
○ Provider discounts are generally higher
○ Networks may contract with "any willing provider" or be selective about accepting providers
- consumer choice
- utilization
Name 3 Commonly recognized types of HMOs: - answer ○ IPAs
○ Network
○ Staff & Group
Explain what an IPA is: - answer Independent Physician Association: Organization that has a
contract with a managed care plan to deliver services in
return for a single capitation rate.
The defining feature of a direct contract model is the HMO is what? - answer Hire their own
doctors
Name at least 3 advantages of an IPA: - answer - Broader physician choice of members
- More convenient geographic access
pg. 3
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