Which is NOT a common type of IDS (Integrated Delivery System)?
PSO
The service area for an HMO depends on the geographic area of its
... [Show More] network
TRUE
State mandated benefits coverage applies to all types of health benefits plans that provide coverage in that state
FALSE
Which is NOT considered to be a type of Defined Health Benefits Plan
a Health Savings Account
The original impetus of HMOs development came from
ALL of the ABOVE:
Providers seeking steady revenue;
Consumers seeking access to health care;
Employers seeking to control costs
Blue Cross began as a Physician Service Bureau in the 1930s
TRUE
PPOs (differ from HMOs because they):
1- do NOT accept capitation risk and
2- enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network
TRUE
This law allowed employers to self-fund benefit plans, in which the employer bears risk for costs, and not the insurer
ERISA
Examples of basic elements of credentialing typically include
onsite office inspection
Which provider contract "clauses" STATES:
the provider agrees not to sue or assert any claims against the enrollee for payments that are the responsibility of the plan
Hold-Harmless Clause
An IDS can be described as:
A legal entity consisting of more than one type of provider to manage a population's health care and/or contract with a payer organization
TRUE
Managed care is best described as
a BROAD and CONSTANTLY CHANGING array of health plans employers, unions, & other purchasers of care that try to MANAGE BOTH COST & QUALITY
Health insurers and Blue Cross Blue Shield plans can act as Third Party Administrators (TPAs)
TRUE
Identify which comes the closest to describing a RENTAL PPO, also called a "LEASED NETWORK"
a Provider Network that contracts with VARIOUS PAYERS to PROVIDE ACCESS and CLAIMS REPRICING
a Physician Practice Management Company (PPMC):
1- manages all support functions and
2- is involved with the clinical aspects if a physicians' practice
FALSE
COPAYMENT is
a FIXED AMOUNT OF MONEY that a MEMBER PAYS for EACH VISIT or PRESCRIPTION
The defining feature of a DIRECT CONTRACT MODEl HMO is the HMO contracting directly with a hospital to provide acute services to its members
FALSE
ANCILLARY services are broadly divided into the following categories
Diagnostic and Therapeutic
Hospital-Based Physicians include all EXCEPT
Cardiologists
Coinsurance is
a PERCENTAGE of the allowable charge that the member is responsible for paying
It is the payer that credential non-physician professionals employed by a facility
FALSE
COST SHARING applies ONLY TO SERVICES that are COVERED BY THE PLAN, NOT to SERVICES or GOODS FOR WHICH THERE IS NOT COVERAGE
TRUE
In a provider contract items that not expected to change with any frequency are placed where
in the BODY of the CONTRACT
The PROVIDER NETWORK is composed of
ALL:
non-physician professionals
facilities
ancillary & therapeutic services
contracted physicians
HIPPA increases right to continuance of health insurance beyond COBRA
TRUE
Defined contribution benefits plan defines a fixed amount of money that may be put towards a benefit
TRUE
The PLATINUM LEVEL of a COST SHARING under the ACA is defined as what
10% or LESS total cost sharing
Coverage under COBRA is limited to 12 months in most cases and the end of that period of coverage is considered a life event for purposes of obtaining coverage thru the health insurance exchange
FALSE
What is one type of Traditional Health Insurance
Indemnity Insurance
The difference between a POINT OF SERVICE (POS) Plan and a PPO is that a POS
COMBINES features of HMO and TRADITIONAL INSURANCE PLANS (ie: indemnity insurance)
In an OPEN ACCESS HMO, members may access any provider in the HMO without going thru a PCP
TRUE
This act REDUCED payment levels to Medicare + Choice HMOs in most of the country below the rate of increase in medical costs
The BALANCED BUDGET ACT of 1997
The Medicare Modernization Act 2003 converted Medicare + Choice program into Medicare Advantage (MA) and provided drug benefits for seniors for the first time
TRUE [Show Less]