WorksheetsNHA Mod 1 Section 1 Foundational Knowledge
Total questions: 27
Worksheet time: 15mins
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
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
POS plans allow a great deal of flexibility for patients. They can self-refer to specialists and do not need an assigned PCP. Like PPO, the cost depends on whether the providers they see are within the plan's panel.
Health maintenance organization (HMO)
Preferred provider organization (PPO)
Capitation (partial or full)
Point-of-service (POS) plan
Managed care
These plans have more flexibility than HMO plans. An insured person does not need a PCP and can go directly to a specialist without referrals. Although patients can see providers in or out of their network, an in-network provider usually costs less.
Point-of-service (POS) plan
Health maintenance organization (HMO)
Preferred provider organization (PPO)
Capitation (partial or full)
Managed care
This plan contracts with a medical center or group of providers to provide preventive and acute care for the insured person. HMOs generally require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpt procedures, and txs.
Managed care
Capitation (partial or full)
Preferred provider organization (PPO)
Point-of-service (POS) plan
Health maintenance organization (HMO)
Which of the following is a feature of a Health Maintenance Organization (HMO) plan?
You must select a primary care physician (PCP)
Specialist visits never require referrals
You can visit any doctor without restrictions
There are no networks of providers
What is typically required before seeing a specialist under most HMO plans?
Paying a higher premium
Obtaining a referral from your primary care physician
Filing a claim form
No requirements; you can see any specialist directly
Which statement best describes a deductible in a health insurance policy?
The amount you pay each month for coverage
The percentage of costs you pay after insurance pays its share
The total cost of all medical services in a year
The fixed amount you must pay out-of-pocket before insurance starts to pay
What is a deductible?
The monthly fee you pay to an insurance company
The specific amount of money a patient pays for a particular service
The amount of money an individual must pay before insurance will pay 100% of expenses for the remainder of the year
The amount that must be paid by the patient for medical services before the policy begins to pay
What is a premium in the context of health insurance?
The amount paid for a doctor's visit
The monthly fee paid to maintain health insurance coverage
The cost of a prescription medication
The fee for a gym membership
Value-Based Plans
improve pt outcomes
improve pt satisfaction
lower cost
health care professional well-being
all are correct
Unwanted or undesired effects that are possibly related to taking a medication, usually secondary to the main effect of the medication.
Point of service (POS)
Side effects
Therapeutic effects
Adverse reactions
Verification by an outside agency that an employer is following established guidelines and standards of care and providing the highest quality of care for their patients.
Managed care
Patient-centered medical home (PCMH)
certification
Point of service (POS)
Statute that identifies all regulated substances into one of five schedules depending on potential for abuse.
Health maintenance organization (HMO)
Managed care
Physician’s Desk Reference (PDR)
Controlled Substances Act
System used by private insurance companies and not-for-profits in which insurance carriers determine the allowed charge either by a fee schedule or through service benefits that define covered services but not necessarily the exact payments.
Health maintenance organization (HMO)
Fee for service
Managed care
Patient-centered medical home (PCMH)
Resource that provides a guide to prescription medication information.
Patient-centered medical home (PCMH)
Point of service (POS)
Fee for service
Physician’s Desk Reference (PDR)
A partnership between a pt and their care team in which total health is the focus and not just a single condition. A health care team consists of a provider (physician, nurse practitioner, physician assistant), CMAA, CCMA, nurses, and pharmacist.
Patient-centered medical home (PCMH)
Managed care
capitation
Point of service (POS)
