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Exam 4: Health: Health Maintenance Organizations

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Question 1

Multiple Choice

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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.

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Question 2

Multiple Choice

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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

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Question 3

Multiple Choice

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One way HMOs differ from traditional health insurance is?

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:

Which of the following is true about HMOs?

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

As an HMO basic member, services

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

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

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

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?

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

What is an open ended HMO plan?

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

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

Preventative health services include all of the following except:

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

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

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

HMOs can terminate services for all of the following except: