PUBH 6012 exam 1 Questions and Answers |Complete Solutions Graded A+ |100% Correct
What are the types of MCOs 1. Health Maintenance Organization (HMO)
2. Preferred Provider Organization (PPO)
3. Point of Service Plan (POS)
What is a HMO - more restricted structure- have a provider network
> staff model: salaried, employee by HMO
> group model: capitation, HMP contracts with group
> network model: same as group model, but more than one group
> individual practice association: discounted FFS, HMO contract with a number of physicians
- gatekeeper- patients have to have referral for specialty care services
- lower payments for members compared to PPO or POS
- Stringent quality and utilization standard
-patients must use provider network
What is a PPO - most popular type of MCO
- more flexible than HMO
- network providers have contractual relationship--> discounted fee schedules
- patients may use in or out of network providers, but out of network providers are more
expensive
,- no gatekeeper, so referrals are not needed to see specialists
- often have fewer utilization controls strategies
What is a POS hybrid model that brings together parts of HMO and parts of PPO:
- can go outside network at higher costs
- gatekeeper --> needs referral from in-network PCP
What are pros of managed care - may provide more plan choices for employees
- incentives for reduced unnecessary care
- may lower costs
- quality controls, quality improvement
- coordinated care
- comprehensive benefits
What are cons of managed care - concern about barriers to necessary care
- interference with provider/patient relationship
- reduced choice of providers in some arrangements
- increased cost for choice of provider in some arrangements
- concerns about quality of care, provider ethical conflicts
What are some other types of insurance plans? - High Deductible Health Plan (HDHP)
- Catastrophic plan
,- Short-term health insurance
What is a fully insured group health plan The employer pays a premium to the insurance
company; the insurance company pays the claims of employees per contract with the
employer.
What is a self-insured (or self-funded) group health plan the employer assumes financial risk
of paying for health care benefits to its employees.
The employers pay for each claim as they are incurred. Usually set up a trust fund to earmark
money to pay claims. May purchase insurance against exceeding the amount available to pay
claims (reinsurance).
The employer may contract with an insurance company to act as a "third-party administrator"
(TPA) to administer the health plan for that company, sometimes using its existing networks
and relationships.
What is the Employee Retirement Income Security Act (ERISA) of 1974? law intended to
protect employee pension system from employer fraud
- supposed to create uniform rules for administration of benefits but mostly addresses fiduciary
responsibilities of plan administrators; no substantive standards for benefit plans
What are the health system measurement dimensions health outcomes
consumption/utilization
access
, quality of care
spending
relationship of spending and outcomes
What were the new rules for insurers under the ACA - can't deny coverage for preexisting
conditions
- only allowed to vary premiums based on age, geographic area, tobacco use, and number of
family members
- no lifetime limits and can't rescind coverage
- young adults can stay on parents' plans up to age 26
- waiting period for coverage limited to 90 days
What did the ACA require in terms of medical loss ratio (MLR) the ACA requires health
insurance issuers to spend a certain percentage of their premium income on medical care and
health care quality improvement, leaving the rest for administration, marketing, and profit
- individual and small group markets = 80%
- large group market = 85%
**if plans do not meet these requirements, they must provide an annual rebate to consumers
What are the essential health benefits under the ACA - ambulatory patient services
(outpatient care)
- emergency services
- hospitalization
- maternity and newborn care
- mental health and substance use disorder services, including behavioral health treatment
What are the types of MCOs 1. Health Maintenance Organization (HMO)
2. Preferred Provider Organization (PPO)
3. Point of Service Plan (POS)
What is a HMO - more restricted structure- have a provider network
> staff model: salaried, employee by HMO
> group model: capitation, HMP contracts with group
> network model: same as group model, but more than one group
> individual practice association: discounted FFS, HMO contract with a number of physicians
- gatekeeper- patients have to have referral for specialty care services
- lower payments for members compared to PPO or POS
- Stringent quality and utilization standard
-patients must use provider network
What is a PPO - most popular type of MCO
- more flexible than HMO
- network providers have contractual relationship--> discounted fee schedules
- patients may use in or out of network providers, but out of network providers are more
expensive
,- no gatekeeper, so referrals are not needed to see specialists
- often have fewer utilization controls strategies
What is a POS hybrid model that brings together parts of HMO and parts of PPO:
- can go outside network at higher costs
- gatekeeper --> needs referral from in-network PCP
What are pros of managed care - may provide more plan choices for employees
- incentives for reduced unnecessary care
- may lower costs
- quality controls, quality improvement
- coordinated care
- comprehensive benefits
What are cons of managed care - concern about barriers to necessary care
- interference with provider/patient relationship
- reduced choice of providers in some arrangements
- increased cost for choice of provider in some arrangements
- concerns about quality of care, provider ethical conflicts
What are some other types of insurance plans? - High Deductible Health Plan (HDHP)
- Catastrophic plan
,- Short-term health insurance
What is a fully insured group health plan The employer pays a premium to the insurance
company; the insurance company pays the claims of employees per contract with the
employer.
What is a self-insured (or self-funded) group health plan the employer assumes financial risk
of paying for health care benefits to its employees.
The employers pay for each claim as they are incurred. Usually set up a trust fund to earmark
money to pay claims. May purchase insurance against exceeding the amount available to pay
claims (reinsurance).
The employer may contract with an insurance company to act as a "third-party administrator"
(TPA) to administer the health plan for that company, sometimes using its existing networks
and relationships.
What is the Employee Retirement Income Security Act (ERISA) of 1974? law intended to
protect employee pension system from employer fraud
- supposed to create uniform rules for administration of benefits but mostly addresses fiduciary
responsibilities of plan administrators; no substantive standards for benefit plans
What are the health system measurement dimensions health outcomes
consumption/utilization
access
, quality of care
spending
relationship of spending and outcomes
What were the new rules for insurers under the ACA - can't deny coverage for preexisting
conditions
- only allowed to vary premiums based on age, geographic area, tobacco use, and number of
family members
- no lifetime limits and can't rescind coverage
- young adults can stay on parents' plans up to age 26
- waiting period for coverage limited to 90 days
What did the ACA require in terms of medical loss ratio (MLR) the ACA requires health
insurance issuers to spend a certain percentage of their premium income on medical care and
health care quality improvement, leaving the rest for administration, marketing, and profit
- individual and small group markets = 80%
- large group market = 85%
**if plans do not meet these requirements, they must provide an annual rebate to consumers
What are the essential health benefits under the ACA - ambulatory patient services
(outpatient care)
- emergency services
- hospitalization
- maternity and newborn care
- mental health and substance use disorder services, including behavioral health treatment
