#1
What is a Health Maintenance Organization (HMO)?
A type of health insurance plan that limits coverage to providers within a specific network
ExplanationLimits coverage to specific network providers.
#2
Which of the following is a characteristic of a Preferred Provider Organization (PPO)?
Offers flexibility to see out-of-network providers at a higher cost
ExplanationAllows out-of-network providers at a higher cost.
#3
What is a Medicare Advantage plan?
A private health insurance plan that provides Medicare coverage
ExplanationPrivate plan providing Medicare coverage.
#4
Which of the following is a characteristic of a Health Maintenance Organization (HMO)?
Requirement for referrals to see specialists
ExplanationRequires referrals for specialists.
#5
What is a Health Savings Account (HSA) used for?
To save money for future medical expenses on a tax-free basis
ExplanationTax-free savings for future medical expenses.
#6
What is a High Deductible Health Plan (HDHP)?
A plan with low monthly premiums and a high deductible
ExplanationLow premium, high deductible plan.
#7
What is a Point of Service (POS) plan in managed healthcare?
A plan that allows members to choose in-network or out-of-network providers for their healthcare needs
ExplanationAllows choice of in-network or out-of-network providers.
#8
In managed healthcare, what is the primary role of a case manager?
To coordinate and manage healthcare services for individual patients
ExplanationCoordinates healthcare services for patients.
#9
What is the purpose of a formulary in managed healthcare?
To manage medication costs and ensure appropriate drug utilization
ExplanationManages medication costs and drug utilization.
#10
What is the role of utilization management in managed healthcare?
To monitor and manage the use of healthcare services to ensure appropriate and cost-effective care
ExplanationEnsures appropriate and cost-effective care.
#11
What is meant by 'capitation' in managed healthcare?
A fixed monthly payment to healthcare providers per enrolled patient, regardless of the services provided
ExplanationFixed monthly payment per enrolled patient.
#12
What is the concept of 'gatekeeping' in managed healthcare?
Requiring patients to obtain a referral from their primary care physician before seeing a specialist
ExplanationRequires referral from primary care physician for specialist visits.
#13
In managed healthcare, what is meant by 'tiered network'?
A network where providers are grouped into different tiers based on cost and quality
ExplanationProviders grouped by cost and quality tiers.
#14
What does the term 'medical underwriting' refer to in the context of managed healthcare?
The process of evaluating a patient's medical history to determine insurance premiums
ExplanationEvaluates medical history for insurance premiums.