Questions and Answers
What does MCO stand for?
What does HMO stand for?
What does POS stand for?
Point of Service
What is a CDHP?
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What does IDS stand for?
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What is the fundamental concept used to spread risk in health insurance?
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What are the three types of board risk bearing?
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What percentage of healthcare is paid for by government programs?
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Government programs can be considered entitlement programs.
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What does CMS stand for?
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What are wraparound policies?
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What is the FEHB?
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What is individual health insurance?
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What is the COBRA Act?
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What is self-funded insurance?
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What are the two types of indemnity insurance?
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What does PPO stand for?
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What is a point of service plan?
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Study Notes
Managed Care Key Terms and Concepts
- MCO (Managed Care Organization): A type of health maintenance organization aimed at managing cost, utilization, and quality of care.
- HMO (Health Maintenance Organization): A managed care plan that typically requires members to use a network of doctors and hospitals.
- POS (Point of Service): A hybrid insurance plan where members can choose between HMO and traditional insurance options at the time of service.
- CDHP (Consumer Direct Health Plan): A health plan model that empowers consumers to make informed health care decisions.
- IDS (Integrated Health Care Delivery System): Organized groups of providers that deliver a continuum of care.
Risk Management in Healthcare
- Risk pooling is a fundamental concept that combines individuals' funds to distribute financial risk associated with medical costs.
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Types of Risk Bearing:
- Government programs
- Insurance
- Self-funded programs
Government Programs
- Government Funding Sources: Account for 40% of healthcare costs through programs like Medicare and Medicaid.
- Entitlement Programs: Programs like Medicaid and Medicare, providing necessary benefits to eligible individuals.
- CMS (Centers for Medicare and Medicaid Services): Federal agency overseeing Medicare and Medicaid programs.
Insurance Types and Structures
- Insurance: Provides coverage for medical expenses with premium rates, co-payments, and limits on certain treatments.
- Group Health Plans: Often offer better pricing due to tax advantages; include other benefits like life insurance.
- Defined Benefit Insurance: Employer-sponsored insurance covering a significant share of costs with employee contributions.
Coverage and Policies
- Wraparound Policies: Supplemental coverage for expenses not covered by Medicare, addressing high deductibles and limits.
- Individual Health Insurance: Typically more expensive than group plans with less coverage; options available for young, healthy adults.
- Insurer of Last Resort: Non-profit health plans offering guaranteed policies to applicants, often at higher costs.
Legislative Framework
- COBRA Act: Allows recently unemployed individuals to retain health insurance from previous employers with a cost increase for up to 18 months.
- HIPAA (Health Insurance Portability and Accountability Act): Mandates protections for health insurance coverage and privacy.
Risk Management and Financing
- Self-funded Programs: Large employers can self-fund health plans, avoiding state premium taxes and mandated benefits by ERISA.
- Third-party Administrators: Companies such as Blue Cross manage health plan activities at a reduced rate.
Managed Care Models
- Payer-based Managed Care: Includes indemnity health insurance, providing coverage without network restrictions.
- PPO (Preferred Provider Organization): Balances provider availability and cost, with credentialing processes for network inclusion.
- POS Plans: Combine HMO and traditional insurance options, allowing member flexibility at varying costs.
Traditional vs. Managed Care
- Traditional Health Insurance: Comprises indemnity and service plans, historically dominant but costlier since the 1970s.
- Indemnity Insurance: Protects against medical expenses under outlined benefits, reimbursing subscribers directly.
- Service Plans: Typically offered by Blue Cross, with few restrictions and direct provider reimbursement.
Current Trends and Changes
- Managed Care Continuum: Incorporates various models reflecting shifts in healthcare administration and reimbursement strategies.
- Risk Bearing: Differentiates between risk-bearing models (where insurance functions are included) and non-risk-bearing networks (focused solely on management).
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Description
Explore key terms related to managed care organizations and risk management in healthcare. This quiz covers important concepts such as HMOs, POS, and various risk-bearing programs. Test your understanding of how these elements work together in the healthcare system.