HSM 3700 final exam

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What is an HMO?

A Health Maintenance Organization (HMO) provides healthcare services for a fixed annual fee, emphasizing preventive care and requiring referrals for specialists.

What is the purpose of the Balanced Budget Act (BBA)? 1997

The BBA aimed to reduce Medicare spending and introduced changes to payment systems affecting hospitals, physicians, and managed care plans.

How do HMOs control healthcare costs?

HMOs control costs through network restrictions, preventive care, and requiring referrals for specialist services.

What impact did the BBA have on healthcare providers?

It altered payment methods and financial incentives for hospitals, physicians, and managed care organizations.

What are the main types of payment models in healthcare?

Fee-for-service, capitation, and value-based care.

What is a bundled payment?

A single payment covering all services related to a treatment episode, encouraging cost efficiency.

What are hospital contracts?

Agreements between insurers and hospitals detailing services provided and reimbursement terms.

What is payment methodology?

The system or method used to reimburse healthcare providers for services rendered.

How does fee-for-service work?

Providers are paid separately for each service they perform.

How does capitation work?

Providers receive a fixed amount per patient, regardless of how many services are provided.

What is the goal of value-based care?

To improve quality of care while controlling costs by linking payment to patient outcomes.

Why are bundled payments beneficial?

They reduce unnecessary services and encourage coordination among providers.

How do hospital contracts impact care delivery?

They define what services are covered, rates, and quality expectations, affecting patient access and cost.

What role does payment methodology play in managed care?

It incentivizes providers to deliver cost-effective and high-quality care.

What is the difference between capitation and fee-for-service?

Capitation pays a fixed rate per patient; fee-for-service pays per service performed.

How can payment models influence healthcare quality?

They can incentivize preventive care, coordination, and better patient outcomes.

What is Medicare Advantage?

A Medicare alternative offered by private insurers that often includes extra benefits like dental or vision.

Who is a Medicare beneficiary?

An individual eligible to receive Medicare coverage.

What are Dual Eligible Special Needs Plans?

Plans designed for individuals eligible for both Medicare and Medicaid, addressing their specific health needs.

What are Managed Medicaid plans?

State-run programs that manage Medicaid services to improve efficiency and quality of care.

What are federal waivers in Medicaid?

Permissions that allow states to implement alternative approaches to Medicaid within federal guidelines.

How does Medicare Advantage differ from traditional Medicare?

It's managed by private insurers and may provide additional benefits and cost structures.

Why are Dual Eligible Special Needs Plans important?

They coordinate care for people with complex needs covered by both Medicare and Medicaid.

How do federal waivers benefit state Medicaid programs?

They allow flexibility in program design to meet state-specific needs efficiently.

What are employer-sponsored health plans?

Health coverage offered by employers to employees, often including group rates and wellness programs.

What is the role of the National Association of Insurance Commissioners (NAIC)?

It sets standards and guidelines for state insurance regulators to ensure fair and effective oversight.

How are health insurers and HMOs regulated?

Through federal and state regulations ensuring solvency, fairness, and compliance with laws.

What is federal preemption in health insurance?

When federal law overrides state regulations, ensuring consistent rules across states.

Why are employer-sponsored plans important?

They expand access to healthcare coverage and reduce costs for employees.