NHA Mod 1 Section 1 Foundational Knowledge

An umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals.

• Managed care

• Health maintenance organization (HMO)

• Capitation

• Preferred provider organization (PPO)

• Point-of-service (POS) plan

Pts are assigned a per-member, per-month payment based on age, race, sex, lifestyle, medical hx, & benefit design. Payment rates are tied to expected usage regardless of how often the pt visits. Like bundled payment models, providers are incentivized to help pts avoid high-cost procedures & tests to maximize their compensation.

• Managed care

• Capitation (partial or full)

• Health maintenance organization (HMO)

• Preferred provider organization (PPO)

• Point-of-service (POS) plan

HMOs force you to pick a doctor from a list

• TRUE

• FALSE

If you have a managed health care plan, it means that you:

• Usually must first meet with your primary health care physician

• Can go to any doctor at any time

• Will be responsible for $100 of a doctor bill

• Can apply for an 80% reimbursement of the amount paid to the doctor

Sally's health insurance policy requires her to pay the first $500 of medical costs each year before the company will pay any of her medical bills.  This policy provision is the:

• Co-insurance clause
• Premium
• Annual deductible
• Major medical benefit

Which is TRUE of health insurance?

• you can only use only the doctors in your state

• you might get a lower standard of care if you don't have insurance

• you won't be able to go to a hospital without insurance

• selecting in-network doctors instead of out-of-network doctors can save you money

A formal request from the customer to an insurance company asking for a payment based on the terms of the insurance policy

• claim

• premium

• deductible

• policy

Identify a characteristic of a Preferred Provider Organization (PPO) plan.

• Requires referrals for specialists

• Offers a network of preferred doctors and hospitals

• Does not cover out-of-network care

• Has no monthly premiums

Capitation payments are fixed payment amounts between insurers and Patients as part of the capitation health care payment system.

• True

• False

What is the main difference between an HMO and a PPO?

• HMOs have higher premiums than PPOs

• PPOs require referrals for specialists, while HMOs do not

• HMOs require you to choose a primary care physician, while PPOs do not

• PPOs do not cover preventive care, while HMOs do