#1
Which entity typically acts as the primary care provider in an HMO?
Primary care physician
ExplanationPrimary care physicians are the main healthcare providers in HMOs, managing overall patient health.
#2
What does 'HMO' stand for?
Health Maintenance Organization
ExplanationHMO stands for Health Maintenance Organization, a type of managed care health insurance plan.
#3
What is a 'provider network' in the context of HMOs?
A group of healthcare providers contracted with the HMO to deliver services to its members
ExplanationA provider network in HMOs consists of contracted healthcare professionals delivering services to HMO members.
#4
What role does a primary care physician (PCP) play in an HMO?
They manage and coordinate the overall healthcare of HMO members.
ExplanationPrimary care physicians (PCPs) in HMOs are responsible for managing and coordinating the comprehensive healthcare of HMO members.
#5
Which of the following is a potential disadvantage of HMOs?
Limited choice of healthcare providers
ExplanationHMOs may have a disadvantage of offering a limited choice of healthcare providers compared to other insurance plans.
#6
Which of the following is a characteristic of an HMO?
Requires referrals to see specialists
ExplanationHMOs typically require referrals from primary care physicians to access specialist healthcare services.
#7
What is 'capitation' in the context of HMOs?
Payment method where providers are paid a fixed amount per patient
ExplanationCapitation in HMOs involves fixed payments to healthcare providers per enrolled patient, regardless of service utilization.
#8
In an HMO, what is the primary method used to control healthcare costs?
Capitation payments
ExplanationCapitation payments are a primary cost control method in HMOs, encouraging efficient and preventive care.
#9
Which of the following is NOT typically covered by an HMO?
Out-of-network specialist visits
ExplanationHMOs generally do not cover out-of-network specialist visits, emphasizing in-network providers for cost-effective care.
#10
What is 'utilization management' in the context of HMOs?
A process for determining the appropriate use of healthcare services
ExplanationUtilization management in HMOs involves assessing and ensuring the appropriate use of healthcare services.
#11
Which federal law primarily regulates HMOs?
Health Maintenance Organization Act of 1973
ExplanationThe Health Maintenance Organization Act of 1973 is the key federal law regulating HMOs in the United States.
#12
What is 'gatekeeping' in the context of HMOs?
The requirement for patients to visit their primary care physician first for referrals
ExplanationGatekeeping in HMOs mandates patients to consult their primary care physician before seeking specialist referrals.
#13
Which government agency oversees the regulation of HMOs at the federal level?
Centers for Medicare & Medicaid Services (CMS)
ExplanationThe CMS is responsible for federal oversight and regulation of Health Maintenance Organizations (HMOs) in the U.S.
#14
What is 'risk sharing' in the context of HMO operations?
A practice of distributing healthcare costs among members
ExplanationRisk sharing in HMO operations involves distributing healthcare costs among members to promote financial stability.
#15
What is 'risk adjustment' in the context of HMO operations?
A process for adjusting capitation payments based on patient health status
ExplanationRisk adjustment in HMO operations involves adjusting capitation payments based on the health status of enrolled patients.