Deck 4: Health: Health Maintenance Organizations

Question 1

What is the purpose of an HMO?

A)Manage health care and costs
B)Manage the providers of health care
C)Increase in health care
D)Decrease costs of health care

Answer 1

Manage health care and costs

Question 2

HMOs focus on preventative medicine. What does this lead to for the industry and consumer?

A)Increased health care costs
B)Increased doctor visits
C)Decreased health care costs
D)Decreased doctor visits

Answer 2

Decreased health care costs

Question 3

One way HMOs differ from traditional health insurance is?

A)HMO provides health care from medical groups
B)Traditional provides for both health care and financial coverage
C)HMO provides financial coverage
D)HMO provides health care and financial coverage.

Answer 3

HMO provides health care and financial coverage.

Question 4

Which of the following is not something an HMO must do to receive government grants?

A)Require only nominal "use charges"
B)Provide undefined health care to cover any situation
C)Maintain certain minimum financial requirements in terms of net worth
D)Establish premiums on a community rating basis

Question 5

Which of the following is true about HMOs?

A)HMOs are not-for-profit
B)HMOs are for-profit
C)HMOs can be either not-for-profit or for-profit
D)HMOs are government programs and do not fall into either of these categories

Question 6

Serendipity HMO contracts with an independent medical group that specializes in a variety of medical services to provide the HMO subscribers comprehensive coverage. Under this arrangement, Serendipity HMO pays the medical group entity not the individual service providers. Serendipity HMO most likely operates as:

A)Group model
B)Staff model
C)Network model
D)Closed panel

Question 7

When contracting physicians are paid as employees generally in a clinic type setting, this is most likely what type of HMO model?

A)Group model
B)Staff model
C)Network model
D)Open panel

Question 8

Fletcher HMO contracts with three medical groups and several independent doctors. What type of HMO model is this most likely to be?

A)Group model
B)Staff model
C)Network model
D)Closed panel

Question 9

Dr. Bobwhite has decided to contract with an HMO because many of his current patients are already subscribers. Dr. Bobwhite will most likely be participating in what type of HMO?

A)Group model
B)Network model
C)Individual Practice Association model
D)Staff model

Question 10

Hereford HMO allows any provider that wants to provide services to the HMO subscribers to do so as long as they agree to Hereford HMO requirements. What type of HMO is this?

A)Open panel
B)Closed panel
C)Network panel
D)Individual practice associations

Question 11

Braunvieh HMO limits the numbers of providers available to the subscribers of the plan. This is most likely a

A)Open panel
B)Closed panel
C)Network model
D)Staff model

Question 12

Which of the following is not a required service of an HMO?

A)Inpatient hospital and physician services
B)Preventative health care
C)Outpatient medical care
D)Long-term care

Question 13

Diagnostic and treatment services fall into which of the following required basic health care services?

A)Inpatient
B)Outpatient
C)Preventative
D)In and out of area emergency services

Question 14

Preventative health services include all of the following except:

A)Well-child from birth
B)Periodic health evaluations
C)Dental care
D)Immunizations

Question 15

As an HMO basic member, services

A)May be subject to a copayment
B)Are subject to additional fees at the time of service
C)Are free to members
D)Are limited to a minimum number of services per period

Question 16

Eric is an HMO subscriber. Which of the following is not a supplemental service he can add to his coverage?

A)Prescription coverage
B)Vision
C)Dental
D)Contact lens replacement

Question 17

What is meant by the term "gatekeeper system"?

A)Members must get authorizations from primary care providers
B)HMO determines the need of care
C)Access to providers is limited
D)Referrals are available only during regular business hours

Question 18

Bill is out of town on a skiing trip in a small village with limited communication to the surrounding areas. Coming down a black diamond run, Bill misses the final turn and breaks his leg as he tumbles to the bottom of the hill. At the emergency room, Bill notes in his paperwork that he is an HMO member. What will the HMO most likely do when Bill notifies them of the accident?

A)Reimburse Bill the set amount they would have paid someone in network
B)Pay the claim even though Bill is outside of his network
C)Deny payment because it was not pre-authorized
D)Pay the claim if an affiliate and charge Bill the overage amount.

Question 19

Fred has a heart condition that has prevented him from obtaining traditional insurance. If he wants to purchase HMO coverage, what should he do?

A)Apply for the HMO during open enrollment
B)Apply for an HMO anytime
C)Not mention his heart condition on the application
D)Falsify his medical records to eliminate notes about his problem

Question 20

HMOs can terminate services for all of the following except:

A)Violation in terms of contract
B)Pre-existing conditions
C)Termination of group contract
D)Non-payment of premiums

Question 21

Which of the following is not a reason for open access HMO?

A)Delays in care
B)Gatekeepers
C)Referral problems
D)Expensive to operate

Question 22

What is an open ended HMO plan?

A)Unlimited coverage
B)Option to add covered services
C)Hybrid arrangement to use non-HMO providers
D)A plan without a termination date

Question 23

What pre-existing condition can prevent HMO coverage during open enrollment?

A)Heart disease
B)Diabetes
C)Physical disabilities
D)None

Question 24

What is a point of service HMO?

A)Member can go outside of HMO providers
B)Members pay for services
C)HMO pays at the time of service
D)HMO only pays for certain services.

Question 25

Which type of plan gives members control of seeing health care specialists?

A)Open access
B)Open ended
C)Point of service
D)Open panel